Adverse Childhood Experience Questionnaire

Give each “Yes” answer one (1) point.

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often: Swear at you, insult you, put you down, or humiliate you?

Or

Act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often: Push, grab, slap, or throw something at you?

Or

Ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way?

Or

Attempt or actually have oral, anal, or vaginal intercourse with you? (Including as a teenager with someone 5+ years older)

4. Did you often feel that: No one in your family loved you or thought you were important or special?

Or

Your family didn’t look out for each other, feel close to each other, or support each other?

5. Did you often feel that: You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

Or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?

7. Were any of your parents or other adult caregivers: Often pushed, grabbed, slapped, or had something thrown at them?

Or

Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

Or

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

10. Did a household member go to prison?

ACE SCORE (Total “Yes” Answers): _______

According to the CDC, ACEs are associated with an increased risk for physical and mental health issues across one’s lifespan. This includes issues such as depression, anxiety, heart disease, and drug and alcohol abuse.

Studies show that having four or more ACEs:

-Is associated with a 390% increase in the likelihood of developing chronic obstructive pulmonary disease (COPD).

-Is associated with a 460% increase in the likelihood of developing depression.

-Increases suicide risk by 1,220%.

We all have adverse childhood experiences that we have gone through, but not everyone has resolved them. Healing our ACEs is an important part of the healing journey because they affect us physically, mentally, and emotionally.

If left unhealed, ACEs contribute to unhealthy patterns in (work/friends/family/partner) relationships and may lead to illness and disease.

Hypnotherapy and Time Line Therapy are two processes that can heal the root cause of your ACEs without having to relive the events. They work rapidly and with lasting results.