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This Questionnaire will be asking you some questions about events that happened during your childhood; specifically the first 18 years of your life. This can be very helpful in the success of your treatment.
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While you were growing up, during your first 18 years of life:
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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?
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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?
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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?
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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?
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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?
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Were your parents ever separated or divorced?
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Were any of your parents or other adult caregivers: Often pushed, grabbed, slapped, or had something thrown at them? Or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
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Were any of your parents or other adult caregivers: Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
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Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
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Was a household member depressed or mentally ill, or did a household member attempt suicide?
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Did a household member go to prison?t
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