Fill Out The Forms Below MEDICAL INTAKE FORM INTAKE FORM PERSONAL INFORMATIONPATIENT(S)Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work Phone*Cell Phone*RESPONSIBLE PARTYResponsible Party's SSN*Address (if different) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone (if different)Work Phone (if different)Cell Phone (if different)Patient’s Relationship to Responsible Party (Check One)*SelfSpouseChildOtherEmergency ContactName* First Last Phone*Relationship*How did you hear about Illuminate Ketamine Center?*FINANCIALFull Name*Enter initials as a digital signature*Today's Date* Date Format: MM slash DD slash YYYY Insurance NameID #Group #Insured PersonRelationshipPRACTICE POLICIESYou will be evaluated by trained and licensed provider. We wish to take this opportunity to welcome you and also to state some basic principles we believe essential in establishing a good relationship between us. Please read through this information, asking questions as needed. INITIAL INTERVIEW: Your first history and physical is considered an evaluation interview and exam. At the time of this appointment, the following decisions will be made with you: a) If ketamine is an appropriate treatment option b) Frequency of ketamine infusion sessions c) Goals of therapy (what you hope to gain from this process.) APPOINTMENTS: Each appointment varies in length depending on your chief complaint. Typically, 40 min infusion appointments take just under 2 hours, 4 hour infusions are typically around 5 hours in length. At the end of each appointment you can make arrangement for your next appointment or you may also book all your prescribed appointments at once. CANCELLATIONS: If you find that you need to cancel an appointment, please give as much notice as possible so that we can schedule people that are on our waiting list. You will be personally charged for your appointment if not canceled at least 24 hours in advance other than for emergency reasons. PAYMENTS: We would greatly appreciate payment in full for each office prior to the start of your appointment. If you do not have a charge card. We will accept cash and check. Please make checks out to Illuminate Ketamine Center PLLC. INSURANCE: Insurance is an agreement between you and your insurance company as to how treatment will be paid for. We will assist you in any way possible by providing receipts and documentation. We currently do not directly participate with insurance plans. However, we will assist you in by giving you receipts to submit, and follow up contacts. Some insurance companies will pay for a portion of outpatient ketamine infusion services. You should check with your insurance company representative to find out specific requirements and limitations of this coverage. We will be happy to assist you in the preparation of insurance forms if you feel there is a chance your insurance company will pay for these services. The hourly rate will apply. Payments for services received through Illuminate Ketamine Center are ultimately your responsibility. If your insurance company requires that outpatient ketamine infusion services be preauthorized, it is your responsibility to initiate the reauthorization process, i.e. contacting your primary care physician, insurance company, or a third party “gate keeper”. Failure to obtain required preauthorization for outpatient mental health services will result in you being held 100% responsible for all charges. CONFIDENTIALITY: All information regarding the specific nature of your treatment is maintained at Illuminate Ketamine Center and is considered confidential within the office unless specified by you in writing. However, each provider at this office reserves the right to use specialty consultation with other medical providers at the office as deemed necessary. We follow HIPAA and maintain confidentiality. Consent* I acknowledge that I have read and understand all of the foregoing statements and that my signature below indicates that I agree to abide by all of the above conditions.Consent I have received a copy of the Privacy Practices Form.Consent I consent to the exchange of treatment information between Illuminate Ketamine Center PLLC and my primary care or mental health provider.Name* First Last Office*Phone*SignatureFull Name*Enter initials as a digital signature*Today's Date* Date Format: MM slash DD slash YYYY HIPPA COMPLIANCE FORM HIPAA COMPLIANCE PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: • Protected health information may be disclosed or used for treatment, payment, or healthcare operations. • The practice reserves the right to change the privacy policy as allowed by law. • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. • The practice may condition receipt of treatment upon execution of this consent. May we phone, email, or send a text to you to confirm appointments?*YesNoMay we leave a message on your answering machine at home or on your cell phone?*YesNoMay we discuss your medical condition with any member of your family?*YesNoIf Yes, please name the members allowed:*Name* First Last Enter your initials to sign electronicly*Date* Date Format: MM slash DD slash YYYY DEPRESSION FORM BECK DEPRESSION INVENTORY Name* First Last DOB* Date Format: MM slash DD slash YYYY QuestionaireThis depression inventory can be self-scored. The scoring scale is at the end of the questionnaire.1.*0 I do not feel sad1 I feel sad2 I am sad all the time and I can’t snap out of it3 I am so sad and unhappy that I can’t stand it2.*0 I am not particularly discouraged about the future1 I feel discouraged about the future2 I feel I have nothing to look forward to3 I feel the future is hopeless and that things cannot improve3.*0 I do not feel like a failure1 I feel I have failed more than the average person2 As I look back on my life, all I can see is a lot of failures3 I severely experience wobbliness in legs and it bothered me a lot4*0 I get as much satisfaction out of things as I used to1 I don’t enjoy things the way I used to2 I don’t get real satisfaction out of anything anymore3 I am dissatisfied or bored with everything5.*0 I don’t feel particularly guilty1 I feel guilty a good part of the time2 I feel quite guilty most of the time3 I feel guilty all of the time6.*0 I don’t feel I am being punished1 I feel I may be punished2 I expect to be punished3 I feel I am being punished7.*0 I don’t feel disappointed in myself1 I am disappointed in myself2 I am disgusted with myself3 I hate myself8.*0 I don’t feel I am any worse than anybody else1 I am critical of myself for my weaknesses or mistakes2 I blame myself all the time for my faults3 I blame myself for everything bad that happens9.*0 I don’t have any thoughts of killing myself1 I have thoughts of killing myself, but I would not carry them out2 I would like to kill myself3 I would kill myself if I had the chance10.*0 I don’t cry any more than usual1 I cry more now than I used to2 I cry all the time now3I used to be able to cry, but now I can’t cry even though I want to11.*0 I am no more irritated by things than I ever was1 I am slightly more irritated now than usual2 I moderately have a feeling of choking and it doesn’t feel pleasant at times3 I severely have a feeling of choking and it bothers me a lot12.*0 I have not lose interest in other people1 I am less interested in other people than I used to be2 I have lost most of my interest in other people3 I have lost all of my interest in other people.13.*0 I make decision about as well as I ever could.0 I make decision about as well as I ever could.2 I have greater difficulty in making decisions more than I used to.3 I can’t make decisions at all anymore.14.*0 I don’t feel that I look any worse than I used to.1 I am worried that I am looking old or unattractive.2 I feel there are permanent changes in my appearance that make me look unattractive.3 I believe that I look ugly.15.*0 I can work about as well as before.1 It takes an extra effort to get started at doing something.2 I have to push myself very hard to do anything.3 I can’t do any work at all.16.*0 I can sleep as well as usual1 I don’t sleep as well as I used to2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep3 I wake up several hours earlier than I used to and cannot get back to sleep17.*0 I don’t get more tired than usual1 I get tired more easily than I used to2 I get tired from doing almost anything3 I am too tired to do anything18.*0 My appetite is no worse than usual.1 My appetite is not as good as it used to be.2 My appetite is much worse now.3 I have no appetite at all anymore.19.*0 I haven’t lost much weight, if any, lately.1 I have lost more than five pounds.2 I have lost more than ten pounds.3 I have lost more than fifteen pounds.20.*0 I am no more worried about my health than usual1 I am worried about physical problems like aches, pains, upset stomach, or constipation2 I am very worried about physical problems and it’s hard to think of much else3 I am so worried about my physical problems that I cannot think of anything else.21.*0 I have not noticed any recent change in my interest in sex1 I am less interested in sex than I used to be2 I have almost no interest in sex3 I have lost interest in sex completelyThe total score is calculated by finding the sum of the 21 items. Score of 0 – 10 = These ups and downs are considered normal. Score of 11 – 16 = Mild mood disturbance. Score of 17 – 20 = Borderline clinical depression Score of 21 – 30 = Moderate Depression Score of 31 – 40 = Severe Depression Score over 40 = Extreme Depression PTSD FORM PTSD Checklist Civilian Version (PCL-C) Name* First Last Date* Date Format: MM slash DD slash YYYY 1. Repreated, disturbing memories, thoughts, or images of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely2. Repreated, disturbing dreams, of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely3. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely4. Feeling very upset when something reminded you of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely5. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely6. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely7. Avoid activities or situations because they remind you of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely8. Trouble remembering important parts of a stressful experience from the past?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely9. Loss of interest in things that you used to enjoy?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely10. Feeling distant or cut off from other people?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely11. Feeling emotionally numb or being unable to have loving feelings for those close to you?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely12. Feeling as if your future will somehow be cut short?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely13. Trouble falling or staying asleep?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely14. Feeling irritable or having angry outbursts?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely15. Having difficulty concentrating?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely16. Being “super alert” or watchful on guard?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) Extremely17. Feeling jumpy or easily startled?*(1) Not at All(2) A little bit(3) Moderately(4) Quite a bit(5) ExtremelyThe PCL is a standardized self-report rating scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD. Two versions of the PCL exist: 1) PCL-M is specific to PTSD caused by military experiences and 2) PCL-C is applied generally to any traumatic event. The PCL can be easily modified to fit specific time frames or events. For example, instead of asking about “the past month,” questions may ask about “the past week” or be modified to focus on events specific to a deployment. How is the PCL completed? • The PCL is self-administered • Respondents indicate how much they have been bothered by a symptom over the past month using a 5-point (1-5) scale, circling their responses. Responses range from 1. Not at all - 5. Extremely How is the PCL scored? 1) Add up all items for a total severity score or 2) Treat response categories 3-5 (Moderately or above) as symptomatic and responses 1-2 (below Moderately) as non-symptomatic, then use the following DSM criteria for diagnosis: • Symptomatic response to at least 1 “B” item (Questions 1-5) • Symptomatic response to at least 3 “C” items (Questions 6-12), and • Symptomatic response to at least 2 “D” items (Questions 13-17) Are results valid and reliable? Two studies of both Vietnam and Persian Gulf theater veterans show that the PCL is both valid and realiable (Additional references are available from the DHCC) Are results valid and reliable? • All military health system beneficiaries with health concerns they believe are deployment-related are encouraged to seek medical care • Patients should be asked, “Is your health concern today related to a deployment?” during all primary care visits. • If the patient replies “yes,” the provider should follow the Post-Deployment Health Clinical Practice Guideline (PDH-CPG) and sup- porting guidelines available through the DHCC and www.PDHealth.mil BECK ANXIETY INVENTORY FORM BECK ANXIETY INVENTORY (BAI) Name* First Last DOB* Date Format: MM slash DD slash YYYY 1.*0 I do not feel numbness or tingling1 I mildly feeling numbness or tingling but it doesn’t bother me much2 I moderately feel numbness or tingling and it wasn’t pleasant3 I severely feel numbness or tingling and it bothered me a lot2.*0 I do not experience feeling hot1 I mildly experience feeling hot but it doesn’t bother me much2 I moderately experience feeling hot and it wasn’t pleasant3 I severely experience feeling hot and it bothered me a lot3.*0 I do not feel wobbliness in legs1 I mildly experience wobbliness in legs but it doesn’t bother me much2 I moderately experience wobbliness in legs and it wasn’t pleasant at times3 I severely experience wobbliness in legs and it bothered me a lot4.*0 I am able to relax1 I am mildly unable to relax but it doesn’t bother me much2 I am moderately unable to relax and it wasn’t pleasant at times3 I am severely unable to relax and it bothered me a lot5.*0 I do not have a fear of the worst happening1 I mildly have a fear of the worst happening but it doesn’t bother me much2 I moderately have a fear of the worst and it is not pleasant at time3 I severely have a fear of the worst and it bothers me a lot6.*0 I do not feel dizziness or lightheadedness1 I mildly feel dizziness or lightheadedness but it doesn’t bother me much2 I moderately feel dizziness or lightheadedness and it doesn’t feel pleasant at times3 I severely feel dizziness or lightheadedness and it bothers me a lot7.*0 I do not feel my hear pounding/racing1 I mildly feel my hear pounding/racing but it doesn’t bother me much2 I moderately my hear pounding/racing and it doesn’t feel pleasant at times3 I severely feel my heart pounding/racing and it bothers me a lot8.*0 I do not feel unsteady1 I mildly feel unsteady but it doesn’t bother me much2 I moderately unsteady and it doesn’t feel pleasant at times3 I severely feel unsteady and it bothers me a lot9.*0 I do not feel terrified or afraid1 I mildly feel terrified or afraid but it doesn’t bother me much2 I moderately feel terrified or afraid and it doesn’t feel pleasant at times3 I severely feel terrified or afraid and it bothers me a lot10.*0 I do not feel nervous1 I mildly feel nervous but it doesn’t bother me much2 I moderately feel nervous and it doesn’t feel pleasant at times3 I severely feel nervous and it bothers me a lot11.*0 I do not have a feeling of choking1 I mildly have a feeling of choking but it doesn’t bother me much2 I moderately have a feeling of choking and it doesn’t feel pleasant at times3 I severely have a feeling of choking and it bothers me a lot12.*0 I do not experience hands trembling1 I mildly experience hands trembling but it doesn’t bother me much2 I moderately experience hands trembling and it doesn’t feel pleasant at times3 I severely experience hands trembling and it bothers me a lot13.*0 I do not feel shaky/unsteady1 I mildly feel shaky/unsteady but it doesn’t bother me much2 I moderately feel shaky/unsteady and it doesn’t feel pleasant at times3 I severely feel shaky/unsteady and it bothers me a lot14.*0 I do not have a fear of losing control1 I mildly have a fear of losing control but it doesn’t bother me much2 I moderately have a fear of losing control and it doesn’t feel pleasant at times3 I severely have a fear of losing control and it bothers me a lot15.*0 I do not have difficulty in breathing1 I mildly have difficulty in breathing but it doesn’t bother me much2 I moderately have difficulty in breathing and it doesn’t feel pleasant at times3 I severely have difficulty in breathing and it bothers me a lot16.*0 I do not have a fear of dying1 I mildly have a fear of dying but it doesn’t bother me much2 I moderately have a fear of dying and it doesn’t feel pleasant at times3 I severely have a fear of dying and it bothers me a lot17.*0 I do not feel scared1 I mildly feel scared but it doesn’t bother me much2 I moderately feel scared and it doesn’t feel pleasant at times3 I severely feel scared and it bothers me a lot18.*0 I do not experience indigestion1 I mildly experience indigestion but it doesn’t bother me much2 I moderately experience indigestion and it doesn’t feel pleasant at times3 I severely experience indigestion and it bothers me a lot19.*0 I do not feel faint/lightheaded1 I mildly feel faint/lightheaded but it doesn’t bother me much2 I moderately feel faint/lightheaded and it doesn’t feel pleasant at times3 I severely feel faint/lightheaded and it bothers me a lot20.*0 I do not have face flushed1 I mildly have face flushed but it doesn’t bother me much2 I moderately have face flushed and it doesn’t feel pleasant at times3 I severely have face flushed and it bothers me a lot21.*0 I do not have hot/cold sweats1 I mildly have hot/cold sweats but it doesn’t bother me much2 I moderately hot/cold sweats and it doesn’t feel pleasant at times3 I severely have hot/cold sweats and it bothers me a lotThe total score is calculated by finding the sum of the 21 items. Score of 0 – 21 = low anxiety Score of 22 – 35 = moderate anxiety Score of 36 and above = potentially concerning levels of anxiety NEUROPATHIC PAIN FORM Neuropathic Evaluation Name* First Last Date* Date Format: MM slash DD slash YYYY Please use the scale below to tell us how intense your pain is. Check the box of the number that best describes the intensity of your pain*0123456789100=No Pain, 10=The most intense pain sensation imaginablePlease use the scale below to tell us how sharp your pain feels. Words used to describe “sharp” feelings include “like a knife,” “like a spike,” “jabbing” or “like jolts.”*0123456789100=Not Sharp, 10=The most sharp sensation imaginable (“like a knife”)Please use the scale below to tell us how hot your pain feels. Words used to describe very hot pain include “burning” and “on fire.”*0123456789100=Not Hot, 10=The most hot sensation imaginable(“on fire”)Please use the scale below to tell us how dull your pain feels. Words used to describe very dull pain include “like a dull toothache,” “aching” and “like a bruise.”*0123456789100=Not Dull, 10=The most dull sensation imaginablePlease use the scale below to tell us how cold your pain feels. Words used to describe very cold pain include “like ice” and “freezing.”*0123456789100=Not Cold, 10=The most cold sensation imaginable("freezing")Please use the scale below to tell us how sensitive your skin is to light touch or clothing. Words used to describe sensitive skin include “like sunburned skin” and “raw skin.”*0123456789100=Not Sensitive, 10=The most itchy sensation imaginable (“like poison oak”)Please use the scale below to tell us how itchy your pain feels. Words used to describe very itchy pain include “like poison oak” and “like a mosquito bite.”*0123456789100=Not Itchy, 10=The most itchy sensation imaginable ("like poison oak")Which of the following best describes the time quality of your pain? Please check only one answer.*I feel a background pain all of the time and occasion flare-ups (break-through pain) some of the time.I feel a single type of pain all of the time.I feel a single type of pain only sometimes. Other times, I am pain free.Describe the background pain*Describe the flare-up (break-through) pain*Describe this pain*Describe this occasional pain* AUTHORIZATION RELEASE OF INFORMATION AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION Purpose and Laws: This form, when properly completed, permits the release of confidential information about a person receiving services (service recipient) governed and regulated by Title 33, Tennessee Code Annotated. Any information to be released under this form shall be released in accordance with the following confidentiality laws and regulations: Title 33, Tennessee Code Annotated; the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its regulations at 45 Code of Federal Regulations (CFR) Parts 160 and 164; and the federal Confidentiality of Alcohol and Substance Abuse Patient Records and its regulations at 42 CFR Part 2. The records released through this Authorization are protected by the above named confidentiality laws and regulations. A general authorization for the release of medical or other information is NOT sufficient for the purpose of disclosing mental health or alcohol and substance abuse information. Federal rules restrict any use of alcohol and substance abuse information to criminally investigate or prosecute the person to whom the information pertains. Further disclosure of this information to parties other than those designated on this form is expressly prohibited without the express written consent of the person to whom the information pertains. I,Name of Service Recipient* First Last Date of Birth* Date Format: MM slash DD slash YYYY , authorizeName of agency/program making disclosure*Mailing address of agency/program making disclosure* Street Address City State / Province / Region ZIP / Postal Code To disclose to (Name of person(s) or organization to which disclosure is to be made, and their mailing address): Illuminate Ketamine Center, 1936 Brookside Drive Suite E, Kingsport, TN 37660The following information (Describe the specific information to be used or disclosed):*The purpose of the authorized disclosure is to (Specific purpose/use of the disclosure): Facilitate treatmentBy signing this form, I (the service recipient) understand that if the person or organization designated on this form to receive the information is not a Health Plan or Health Care Provider, some of the released information may no longer be protected by the above named confidentiality laws and regulations. I also understand that signing this Authorization is voluntary, and that I am not required to sign this Authorization in order to get treatment, payment, enrollment, or eligibility for benefits. I also understand that I may revoke this Authorization by doing so in writing at any time; except to the extent that action has been taken in reliance on the information, and that the revocation does not affect any information that was released before the revocation. Even if I do not revoke this Authorization, the Authorization expires automatically one (1) year from the date of signature or as follows: Specify the date, event, or condition of expiration* Date Format: MM slash DD slash YYYY Signature of service recipient who is 16 years of age or older ** First Last Enter your initials to sign electronicly*Date* Date Format: MM slash DD slash YYYY *If a service recipient gives oral consent or signs with an X, this form must be signed by two (2) witnesses:Witness First Last Date Date Format: MM slash DD slash YYYY Witness First Last Date Date Format: MM slash DD slash YYYY Signature of individual acting on behalf of the service recipient ** First Last Enter your initials to sign electronicly*Date Date Format: MM slash DD slash YYYY ** If the individual signing this form is acting on behalf of the service recipient, the individual is: (1) the parent, legal guardian, or legal custodian of a service recipient who is under 18 years of age; (2) the conservator or guardian for the service recipient; (3) the guardian ad litem of the service recipient but only for the purposes of the litigation in which the guardian ad litem serves; (4) the attorney-in-fact under a power of attorney who has the right to make disclosures under the power for the service recipient; (5) the executor, administrator, or personal representative on behalf of a deceased service recipient; and (6) the treatment review committee, acting within the authority and scope of Tennessee Code Annotated Section 33-6-107. Appropriate documentation of proof of this individual’s authority to act on behalf of the service recipient must be submitted to the entity being asked to release the information before any information will be released. ADVERSE CHILDHOOD EXPERIENCE (ACE) QUESTIONNAIRE Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score Name* First Last Date* Date Format: MM slash DD slash YYYY 1. 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?YesNo2. 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?YesNo3. 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 Try to or actually have oral, anal, or vaginal sex with you?YesNo4. Did you 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?YesNo5. 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?YesNo6. Were your parents ever separated or divorced?*YesNo7. Was your mother or stepmother:*Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?YesNo8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*YesNo9. Was a household member depressed or mentally ill or did a household member attempt suicide?*YesNo10. Did a household member go to prison?*YesNoNow add up your “Yes” answers. This is your ACE Score