Self-Injury Survey

What is your gender?

• Male
• Female

How old are you?

• 10 or younger
• 11-13
• 14-15
• 16-17
• 18-19
• 20+

When did you first start self-injurying?

• Younger than 7
• 7-8
• 9-10
• 11-12
• 13-14
• 14-15
• 16-17
• 18-19
• 20+

How often do/did you self-injury?

• More than once a day
• Once a day
• A few times per week
• 1-3 times a month
• Several times per month
• 1-3 times per year
• Several times per year
• Random

What method(s) do/did you use?

Please select all that apply.

• Cutting
• Burning
• Scratching
• Hitting
• Other

Do you plan to stop self-injuring?

Please select all that apply.

• No, at least not in the near future.
• Yes, I plan on stopping in the near furture.
• I am working on stopping.
• I no longer self-injury. Yay! :)

Which of the following also are challenges for you?

Please select all that apply.

• Drug Abuse
• Alcohol Abuse
• Tobacco Abuse
• An Eating Disorder
• Psychiatric Disorder (such as Depression or an Anxiety Disorder)
• Family/Friends/Peers
• Academics
• Abuse (either current or past)
• Other
• None of The Above

If You Have Scars form Self-Injury, do you keep them hidden?

• Yes
• No
• It depends
• Other
• N/A

Does anybody know about your self-injury?

Please select all that apply.

• Nobody but myself knows.
• Yes, my parents or a few, close family members.
• Yes, a few close friends.
• Yes, a few people know.
• Yes, many people know.
• Other.