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Prior to your 18th birthday:


  1. Did a parent or other adult in your household often or very 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?  YES/NO

  2. Did a parent or other adult in the household or very often…push, slap, or throw something at you? Or Ever hit you so hard that you had marks on your body or were injured? YES/NO

  3. Did an adult or person at least 5 years or older than you ever ….Touch or fondle you or have them touch their body in a sexual way? Or attempt to actually have oral, anal or vaginal intercourse with you? YES/NO

  4. Did you often or very often feel that…No one in your family loved you of 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

  5. Were your parents or grandparents ever separated or divorced? YES/NO

  6. 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?  YES/NO

  7. Did you live with anyone who was a problem drinker or alcholic or who used street drugs? YES/NO

  8. Was a household member depressed or mentally ill, or did a household member attempt suicide? YES/NO

  9. Do you experience violence in your community? YES/NO

  10. Did a household member go to prison? YES /NO? YES /NO

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