“It’s so incredible to finally understand myself.”

Question 1 of 10

Before your 18th birthday, did a parent or other adult in the household often or very often…
swear at you, insult you, put you down, or humiliate you?
Yes No

Question 2 of 10

Before your 18th birthday, 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

Question 3 of 10

Before your 18th birthday, did an adult or person at least five 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

Question 4 of 10

Before your eighteenth birthday, 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

Question 5 of 10

Before your 18th birthday, 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

Question 6 of 10

Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason?
Yes No

Question 7 of 10

Before your 18th birthday, was your mother or stepmother:
often or very often pushed, grabbed, slapped, or had something thrown at her?
or
sometimes, often, or very 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

Question 8 of 10

Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Yes No

Question 9 of 10

Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes No

Question 10 of 10

Before your 18th birthday, did a household member go to prison?
Yes No

Has anything important happened before your 18th birthday that you think we should have covered?

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Please answer these additional questions: