Adverse Childhood Experiences Questionnaire (copy)
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.
TERMS AND CONDITIONS:
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:
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:
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.