Self harm survey

1. How old were you when you started self-harming?

[ ]
4-5 
[ ]
6-7
[ ]
8-9 
[x] 
10-11
[ ] 
12-13 
[ ] 
14-15 
[ ]
15-16
[ ] 16-17 
[ ]
18-19
[ ]
20-21
[ ] 
Older than 22

How often do you self-harm?

[x] It really all depends

[ ] More than once a day

[ ] Once a day

[ ] Several times a week
[ ] Once a week

[ ] Two or more times a month

[ ] Once a month

[ ] Several times in a year 

[ ] Once a year 

[ ] I have stopped 

[ ] I am trying to stop 

3. What method of self-harm do/did you primarily use?

[x] Cutting

[ ] Burning

[ ] Hair-pulling

[x] Scratching

[x] Interference with the healing of wounds

[ ] Hitting or bruising

[ ] Bone breaking

[x] Cutting and Scratching

[ ] Cutting and Burning

[x] Hitting Head against walls

[ ] Binging

[ ] Purging

[x] Starving

[x] Biting

[x] Rubber band slaps
[ ]Burning with hot water



4. Which Of These, If Any, Are Something You Struggle With Along With Self-harm?

[\] Anorexia (sort of..)

[ ] Bulimia

[ ] Anorexia and Bulimia

[ ] EDNOS (self diagnosed)

[x] Suicidal (self diagnosed)

[x] Various Psychiatric Disorders (i.e. Bi-polar, Borderline Personality, OCD, Panic, Anxiety, PTSD, Dissociative, Impulse Control Etc.)

[ ] Learning Disabilities

[ ] None of the Above ~Not Diagnosed with anything~



5. Do You Think That You (as An Individual) Need Professional Help To Stop Self-harming? 
[ ] Yes, The Only Way I Could Stop Is With Professional Help

[ ] No, I Have Stopped On My Own Though I Still Struggle Often And Sometimes Mess Up 

[x] I Have No Desire To Stop And Therefore Don’t Need Professional Help 

[ ] Yes, I Have Stopped With Professional Help

[ ] I don’t think I could ever stop without Professional help
[ ] Prefer not to answer 
[ ] I don’t know 



6. Are You Trying To Stop Self Harming?

[ ] No, And I Don’t Want To Stop.

[ ] No, But I Would Like To Be Able To Stop

[ ] Yes, But I Am Not Doing Very Well

[ ] I Have Stopped But I Still Mess Up Every Once In A While

[ ] I Am Completely Self Harm free

[x] Yes, but I don’t want to



7. Does Anyone Know About Your Self Harm? 

[ ] No. No One Knows 

[x] Some People May Have A Vague Idea Of Something

[ ] Yes, But Only My Closest Friend (s) 

[ ] Yes. But Only Some Of My Family Member(s)

[x] Yes, Some Friend(s) And Family Member(s) Know

[ ] Yes, All (or Most Of) My Friends Know

[ ] Yes, All (or Most Of) My Family Know

[ ] Yes, People that see my scars/cuts

[ ] Just a couple of people I trust

[ ] Yes, My Therapist, Psychiatrist, etc



8. How many years have you been self-harming? 

[ ] 1 year 

[ ] 2 years

[ ] 3 years

[ ] 4 years

[x] 5 years

[ ] 6 years

[ ] 7 years 

[ ] 8 years

[ ] 9 years
[ ] 10 or more years 



9. If You Self-harm, Were You Abused Or Neglected (either As A Child Or Later In Life)?

[x] No

[ ] Yes, I Was Emotionally Abused

[ ] Yes, I Was Physically Abused

[ ] Yes, I Was Sexually Abused

[ ] Yes, I Was Emotionally And Physically Abused

[ ] Yes, I Was Physically And Sexually Abused

[ ] Yes, I Was Sexually And Emotionally Abused

[ ] Yes, I Was Emotionally, Physically And Sexually Abused (

[ ] Yes, I Was Neglected

[ ] Yes, I Was Neglected As Well As Being Abused

[ ] Prefer not to answer 



10. Would you label yourself as emo?

[ ] Yes

[x] No

[ ] I guess..?



11. Do others label you as emo?

[ ] Yes

[ ] No

[x] Some People

[ ] I don’t know 



12.What would you or others label you as? (chose all that apply) Please select all that apply.
[ ] Prep

[ ] Goth 

[ ] Emo

[ ] Punk

[ ] Nerd

[ ] Hipster 

[ ] Pothead

[ ] Poser

[ ] Skater

[ ] Druggie

[ ] Normal
[x] I don’t believe in labels



13. What is your reaction when you see other people’s self-harm scars/cuts/marks? (choose all that apply)

[x] I want to get to know them

[x] I wonder what they went through to feel that was a way out

[ ] I want to get as far as possible from them so no one will find out about my own self-harm

[x] I will acknowledge them as someone who shares something in common with me

[ ] I would never even acknowledge them

[x] What happened for them to start cutting
[ ] Fear 

[x] Interest 

[x] Sadness

[ ] Happiness

[ ] Don’t really care

[ ] No reaction

[ ] Surprise

[ ] Relief 

[x] Jealousy

[ ] Upset that nobody else cuts as bad as me

[\] Happy that nobody else cuts as bad as me (sort of)