Before your 18th birthday, did a parent or other adult in the household swear at you, insult you, put you down, humiliate you act in a way that made you afraid that you might be physically hurt? *

Yes

No

Before your 18th birthday, did a parent or other adult in the household push, grab, slap, throw something at you or ever hit you so hard that you had marks or were injured? *

Yes

No

Before your 18th birthday, did a parent or other adult in the household 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

Do you believe no one in your family loved you, 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

Before your 18th birthday there were times when 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

Were your parents ever separated or divorced?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Did a household member go to prison?

Yes

No

First Name

Email *

NEXT