Adverse Childhood Experiences Questionnaire

Overview of this Questionnaire

This standardized survey questionnaire aims to facilitate a more convenient experience for you to determine your mental health condition and identify the most suitable treatment plan including need to undergo further psychological evaluation.  As a preliminary screening tool, it will provide indicators of childhood adverse experiences that may be suggestive of harmful behaviors, which would warrant immediate attention by a trained clinician for further assessment and recommendation.

Please keep in mind that this is doesn't constitute a result for a full diagnosis and that you may be requested to answer other standardized psychological tests or be invited for a clinical collateral interview by our trained clinician after completing this questionnaire, to complete a thorough assessment. 

Carefully review all fields and provide complete and accurate information. There is no right or wrong answer.  

Your trust and confidence are important to us. All the information gathered through this form will be treated with the utmost confidentiality. To ensure that MindWell by CML Well-being and Psychological Services remains a trustworthy partner in this journey towards supporting your mental health and well-being,  we make every effort to comply fully with the existing laws and regulations that govern us.

Kindly read through the terms and conditions for your acceptance.
In compliance with the Data Privacy Act (DPA) of 2012,  you understand and agree that by providing your personal data, you are agreeing and giving your full consent to CML Well-being and Psychological Services to collect, store, access, and/or process any personal data you may provide herein, such as but not limited to your name, mobile number and email address, whether manually or electronically, for the period allowed under the applicable law and regulations, and solely for the purposes of your counseling. You acknowledge that the collection and processing of your personal data are necessary for such purposes. You are aware of your right to be informed, to access, to object, to erasure or blocking, to damages, to file a complaint, to rectify and to data portability, and you understand that there are procedures, conditions, and exceptions to be complied with in order to exercise or invoke such rights.  All such information shall be purged from our records after the closure of your counseling services/engagement with us as prescribed by law.
By using this form, you accept the responsibility for and agree on the following:
  1. Supplying, checking, and verifying the accuracy and correctness of the information provided on this system in connection with your registration, test-taking, and consent to the collection and use of your personal information. 
  2. You understand that in the event that you have any question, you may chat with us at
  3. You are allowed to refuse completing this survey and we would appreciate you notify us with 24 hours after receiving this so we can address this matter accordingly.

INFORMED CONSENT:  This survey questionnaire is a standardized psychological test which we have made available electronically and includes your informed consent prior completion, highlighting the following:

  1. You certify that you have freely participated and in the completion of this form and as applicable, for coaching/consultation, counseling/guidance/therapy session at the date and time scheduled, which you personally or a person you authorized arranged or was made known, and which you concurred. Also, you agree that your mental health professional may determine that due to certain circumstances, telepsychology could at any point of your session/s be no longer appropriate and you agree to resume sessions in-person.
  2. You have likewise been assured that the results of the interview, presenting issues, all other information including but not limited to test results, if any, shall be kept confidential and shall not be disclosed to anyone without your consent and approval in writing.
  3. You agree to the use of technology for the session/s. This is a HIPAA compliant platform that uses video and audio technology through a webcam on your device and our device to connect us securely. You understand that you are solely responsible for maintaining the strict confidentiality of your user ID and password and not allow another person to use your user ID to access the Services. You also understand that you are responsible for using this technology in a secure and private location so that others cannot hear your conversation.  Furthermore, you understand that you are not allowed to do any recording, screenshots, etc. of any kind, of this form or any session, and are grounds for termination of your participation and if any, of the client-coach/counselor/therapist relationship.
  4. Through this form, the information gathered, assessment results, the purpose, duration, and specific instructions were clearly stated to you and you understand that MindWell, as your service provider, will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for an online session.
  5. You understand and agree that upon completion of this form, you will participate in the planning of your child/student's care, treatment, or services and that you may withdraw consent for such care, treatment, or services at any time.
Kindly click "I Accept the Terms and Conditions" button to indicate your consent and confirming you acknowledged the terms and conditions of your session/s.  By clicking the OK button of this Informed Consent, you acknowledge that you have both read and understood all the terms and information contained herein, ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you.

Please be informed that when you choose not to click the "I Agree with Terms and Condition" button, you won't be able to proceed with the survey questionnaire and are encouraged to contact our well-being and psychological services director at [email protected] for further clarification or assistance you may need.

Instructions for Completion

In this test are questions based on childhood experiences you need to recall.  Read carefully and mark in the appropriate column your response, yes or no based on your experience.