(11-17) PEARLS Self-Report Instructions At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences. Please note, some questions have more than one part separated by "OR". If any part of the question is answered "yes," then the answer to the entire question is "Yes". Part OneHas you ever lived with a parent/caregiver who went to jail/prison? Yes No Have you ever felt unsupported, unloved and/or unprotected? Yes No Have you ever lived with a parent/caregiver who had mental health issues? Yes No (for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)Has a parent/caregiver ever insulted, humiliated, or put you down? Yes No Have your biological parent or any caregiver ever had, or currently has a problem with too much alcohol, street drugs or prescription medications use? Yes No Have you ever lacked appropriate care by any caregiver? Yes No (for example, not being protected from unsafe situations, or not cared for when sick or injured even when the resources were available)Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or humiliated by another adult? Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched, beaten up or hurt with a weapon? Yes No Has any adult in the household often or very often pushed, slapped or thrown something at you? Or has any adult ever hit you so hard that your child had marks or was injured? Or has any adult in the household ever threatened you or acted in a way that made you afraid you might be hurt? Yes No Have you ever experienced sexual abuse? Yes No (for example, anyone touched you or asked you to touch that person in a way that was unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with you)Have there vere been significant changes in the relationship status of your caregiver(s)? Yes No (for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)Total for Part 1 Part TwoHave you ever seen, heard, or been the victim of violence in your neighborhood, community or school? Yes No (for example, targeted bullying, assault or other violent actions, war or terrorism)Have you experienced discrimination? Yes No (for example, being hassled or made to feel inferior or excluded because of your race, ethnicity, gender identity, sexual orientation, religion, learning difference, or disabilities)Have you ever had problems with housing? Yes No (for example, been homeless, not having a stable place to live, moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)Have you ever worried that you did not have enough food to eat or that the food would run out before you or your parent/caregiver could buy more? Yes No Have you ever been separated from your parent or caregiver due to foster care, or immigration? Yes No Have you ever lived with a parent/caregiver who had a serious physical illness or disability? Yes No Have you ever lived with a parent or caregiver who died? Yes No Have you ever been detained, arrested or incarcerated? Yes No Have your ever experienced verbal or physical abuse or threats from a romantic partner? Yes No (for example, a boyfriend or girlfriend)Total for Part 2Client Name(Required) First Last Email(Required) If other than patient's signature, relationship to patient
