JFRC - Adverse Childhood Experiences Scale ACES

Adverse Childhood Experiences Scale (ACES)

Name of person completing this form (last name, first name)

Client Code

Date (mm/dd/yyyy)

Please describe the client's progress in the program at the time of scale completion

Please describe the client's progress in the program at the time of scale completion
	Current Phase			Phase History


	Phase 1	Phase 2	Phase 3	1st attempt at current phase	2nd attempt at current phase	3rd attempt at current phase
Client Progress

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

**While you were growing up, during your first 18 years of life**:
	Yes	No
1. Did a parent or other adult in the household often or very 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?	Yes	No
2. Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?	Yes	No
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?	Yes	No
4. Did you often or very 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?	Yes	No
5. Did you often or very 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?	Yes	No
6. Were your parents ever separated or divorced?	Yes	No
7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? 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?	Yes	No
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?	Yes	No
9. Was a household member depressed or mentally ill or did a household member attempt suicide?	Yes	No
10. Did a household member go to prison?	Yes	No
11. Did you experience commercial sexual exploitation? (someone engaged in sexual activity for the financial benefit of any person in exchange for anything of value, including non-monetary items such as food, shelter, drugs, or protection from any person).	Yes	No