1: How old were you when you started self-harming?
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 (depends on the 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
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
Asexual Panromantic Bigender
5: Which Of These, If Any, Are Something You Struggle With Along With Self-harm?
Anorexia
Bulimia
Anorexia and Bulimia
EDNOS
Suicidal Ideation
Various Psychiatric Disorders (i.e. Bi-polar, Borderline Personality,OCD,Panic,Anxiety, PTSD, Dissociative, Impulse Control Etc.)Learning Disabilities,Severe Depression
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 don’t know if I’m ready To Stop.
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 (2 of them)
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?
Less than 1 year
1 year
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
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
11: Would you label yourself as emo?
Yes
No
12: Do others label you as emo?
Yes
No
Some people
13: What would you or others label you as?
Please select all that apply.
Prep
Goth
Emo (some others would)
Punk
Nerd
Hipster
Poser
Skater
Jock
Scene
Gangster
Different
I don’t do labels
There aren’t really any labels above that fit me
Normal (others)
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 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
Happines
Don’t really care
No reaction
Surprise
Relief
Jealousy