PART 1: Please check “Yes” where apply
Has your child ever lived with a parent/caregiver who went to jail/prison?
Do you think your child ever felt unsupported, unloved and/or unprotected?
Has a parent/caregiver ever insulted, humiliated, or put down your child?
Has the child’s biological parent or any caregiver ever had, or currently has a problem with too much alcohol, street drugs or prescription medications use?
Has your child ever lacked appropriate care by any caregiver? (for example, not being protected from unsafe situations, or not cared for when sick or injured even when the resources were available)
Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or humiliated by another adult? Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched beaten up or hurt with a weapon?
Has any adult in the household often or very often pushed, grabbed, slapped or thrown something at your child? Or has any adult in the household ever hit your child so hard that your child had marks or was injured? Or has any adult in the household ever threatened your child or acted in a way that made your child afraid that they might be hurt?
Has your child ever experienced sexual abuse? (for example, anyone touched your child or asked your child to touch that person in a way that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)
Have there ever been significant changes in the relationship status of the child’s caregiver(s)? (for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)
PART 1: Please check “Yes” where apply
Has your child ever seen, heard, or been a victim of violence in your neighborhood, community or school? (for example, targeted bullying, assault or other violent actions, war or terrorism)
Has your child experienced discrimination? (for example, being hassled or made to feel inferior or excluded because of their race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)
Has your child ever had problems with housing? (for example, being homeless, not having a stable place to live, moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)
Have you ever worried that your child did not have enough food to eat or that the food for your child would run out before you could buy more?
Has your child ever been separated from their parent or caregiver due to foster care, or immigration?
Has your child ever lived with a parent/caregiver who had a serious physical illness or disability?
Has your child ever lived with a parent or caregiver who died?
Has your child ever been detained, arrested or incarcerated?
Has your child ever experienced verbal or physical abuse or threats from a romantic partners? (for example, a boyfriend or girlfriend)
