- Younger than 4
- 4-5
- 6-7
- 8-9
- 10-11
- 12-13
- 14-15
- 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
- I am trying to stop
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
- Snapping Rubber Bands
- Digging Nails Into Skin
- Bone breaking
- Writing/Carving on self
- Cutting and Burning
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, were something you struggle with along with self-harm?(diagnosed)
- Anorexia
- Bulimia
- ED-NOS
- Anorexia and Bulimia
- Suicidal Ideation
- Various Psychiatric Disorders
- Learning Disabilities(ADD)
- A Mixture of the Above
- None of the Above
- I don’t have a clue.
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 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
- I don’t know.
7. Are you trying to stop self harming?
- No, And I Don’t Want To Stop Ever.
- 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 One Or Two
- Yes. But Only Some Of My Family Members
- Yes, Some Friends And Family Members 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
- 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 (sexual assault)
- 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
11. Would you label yourself as emo?
- Yes
- No
- I don’t know
12. Do others label you as emo?
- Yes
- No
I don’t know
13. What would you or others label you as? (chose all that apply)
- Prep
- Goth
- Emo
- Punk
- Nerd
- Poser
- Skater
- Jrock
- Scene
- Gangster
- Other- Idk
- I don’t do labels
- There aren’t really any labels above that fit me
- Normal
- Muso
14. What is your reaction when you see other people’s self-harm scars/cuts/marks? (choose all that apply)
- I want to get to know them
- I wonder what they went through & if they are like me
- 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
