Finding Your ACE Score

Each "Yes" answer is 1.

Did a parent or other adult in the household often or very often ... Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you ai-aid that you might be physically hurt?

Did a parent or other adult in the household often or very often ... Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured?

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?

Did you often or very often feel that ... No one in your family loved you or 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?

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? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Were your parents ever separated or divorced?

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 Ever repeatedly hit at least a few times or

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

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

Did a household member go to prison?

Add up all your "yes" answers, this is your ACE score. Please put your score below.

Statement of Release

I certify that all the information on all 3 online forms are accurate and true to the best of my knowledge.

I understand that any false or incomplete information on any of these forms may result in the disqualification of any application for entrance.

I also hereby give permission to Safe Haven staff to use any means necessary to verify this application including talking to my friends, family, any employer past or present, and searching social networks sites.

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Safe Haven does not discriminate against those who are HIV positive in its admissions procedures. Because a large number of IV drug users have been infected by the HIV virus, at any given time there may be one or more residents in the program that are HIV positive. This center does not require students that are HIV positive to notify others in the program of their HIV status.

Safe Haven complies with title IV of the civil rights act of 1964 and does not discriminate based on race, creed, gender or religion.

Safe Haven Intake Summary Letter

Finding Your ACE Score

Statement of Release