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Mat-Su Office 907-373-4732
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Phone 907-373-4732
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Home
About
Meet The Staff
SFA Board of Directors
Founders Video
Strategic Plan
2022 Annual Report
2021 Annual Report
2020 Annual Report
2019 Annual Report
Press & Support
Crisis
Services
Outpatient Services – Mat-Su
Outpatient Services – Homer
Children / Adolescent Services
Women’s Residential Treatment
Men’s Residential Treatment
Recovery Residence
Assessment
Upload Documents
Notice of Privacy Practices
Events
Donations
Testimonies
Find Us On YouTube
Employment
Swag Store
Contact
Mat-Su Office 907-373-4732
Homer Office 907-235-4732
ACE Questionnaire
Which Office Are You Working With?
*
Homer Office
Mat-Su Office
Name
First
Last
Date
MM slash DD slash YYYY
Email
*
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? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
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? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
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 Try to or actually have oral, anal, or vaginal sex with you? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
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? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
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? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
6. Were your parents ever separated or divorced? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
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
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
9. Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
10. Did a household member go to prison? Yes No
*
Yes
No
If yes enter 1. If No enter 0
*
Please enter a number from
0
to
1
.
Now add up your “Yes” answers: This is your ACE Score
Total
*
Please enter a number from
0
to
10
.
Δ
