SELF-HARM SURVEY.

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

• Younger than 4
• 4-5
• 6-7
• 8-9
• 10-11
• 12-13
• 14-15
• 15-16
• 16-17
• 18-19
• 20-21
• Older than 21

2) How often do you self-harm?

• 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

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

• Cutting
• Burning
• Hair-pulling
• Scratching
• Interference with the healing of wounds
• Hitting or bruising
• Bone breaking
• Cutting and Scratching
• Cutting and Burning
• Hitting Head against walls
• Binging
• Purging
• Starving

4) If You Self Harm What Sexual Orientation Are You?

• Straight Male
• Straight Female
• Bi-Sexual Male
• Bi-Sexual Female
• Homosexual Male
• Homosexual Female
• Transgender Male
• Transgender Female
• Questioning Male
• Questioning Female
• Pan-sexual Male
• Pan-Sexual Female
• Prefer not to answer

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

• Anorexia
• Bulimia
• Anorexia and Bulimia
• Possibly EDNOS
• Suicidal Ideation
• Various Psychiatric Disorders (i.e. Bi-polar, Borderline Personality, OCD, Panic, Anxiety, PTSD, Dissociative, Impulse Control Etc.)
• Learning Disabilities
• A Mixture of the Above
• None of the Above

6) 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
• No, I Have Stopped On My Own Though I Still Struggle Often And Sometimes Mess Up
• 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 with or without Professional help
• Prefer not to answer
  

7) 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

8) Does Anyone Know About Your Self Harm?

• No. No One Knows.
• Some People May Have A Vague Idea Of Something
• Yes, But Only My Closest Friends
• Yes. But Only Some Of My Family Member(s)
• Yes, Some Friend(s) And Family Member(s) Know
• Yes, All (or Most Of) My Friends Know
• Yes, All (or Most Of) My Family Knows
• Yes, Most Of The People In My Life Know

9) How many years have you been self-harming?

• 1 or less years
• 2 years(ish)
• 3 years 
• 4 years
• 5 years
• 6 years
• 7 years
• 8 years
• 9 years
• 10 or more years

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

• 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 To Not Anwser

11) Would you label yourself as emo?

• Yes
• No

12) Do others label you as emo?

• Yes (they did at the time, and honestly, looking back, I think I would too)
• No

13) What would you or others label you as? (chose all that apply)

• Prep
• Goth
• Emo
• Punk
• Nerd
• Hipster
• Poser
• Skater
• Jock
• Scene
• Gangster
• Other
• I don’t do labels
• Normal

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

Please select all that apply.

• I want to get to know them
• 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
• I will acknowledge them as someone who shares something in common with me
• I would never even acknowledge them
• Fear
• Interest
• Sadness
• Happiness
• Don’t really care
• No reaction
• Surprise
• Relief
• Jealousy
• [I want to help, but I don’t know how.] 

(Source: helplessbystander)