Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you? *

Yes

No

Did you lose a parent through divorce, abandonment, death, or other reason? *

Yes

No

Did you live with anyone who was depressed, mentally ill, or attempted suicide? *

Yes

No

Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs? *

Yes

No

Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other? *

Yes

No

Did you live with anyone who went to jail or prison?

Yes

No

Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes

No

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Yes

No

Did you feel that no one in your family loved you or thought you were special?

Yes

No

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Yes

No

NEXT