Self Harm/Self Injury Survey

I'm:

• Male
• Female

How old are you?

• 6 - 8 years
• 8 - 10 years
• 10 - 12 years
• 12 - 14 years
• 14 - 18 years
• 18 - 25 years
• 25 - 40 years
• 40 - 65 years
• +65 years

Do you self harm?

• Yes.
• I did, but I stopped.
• No.
• No, but I'll do it.

Do you know someone that self harms?

• Yes.
• No.

If yes, how many?

• 1 or 2.
• 3 to 5.
• 5 to 8.
• More than 8.
• I don't know anyone.

How long do you self harm?

• Less than a month.
• Between a month and 6 months.
• Between 6 months and a year.
• Between a year and 3 years.
• Between 3 and 6 years.
• More than 6 years.
• I don't self harm.

When did you start self harming?

• Before 4 years old.
• 5 - 6 years old.
• 7 - 8 years old.
• 9 - 10 years old.
• 11 - 12 years old.
• 13 - 14 years old.
• 15 - 18 years old.
• 18 - 25 years old.
• 25 - 40 years old.
• 40 - 65 years old.
• After 65 years old.
• I don't self harm.

Why do you self harm?

Please select all that apply.

• To feel the pain.
• Because of emotional pain.
• I'm/I was bullied.
• Peer pressure.
• For atention.
• I've a disorder or a disease.
• To punish myself.
• To be cool.
• To see the blood.
• To feel alive.
• Because I'm/I was depressed.
• I couldn't handle my feelings.
• I was abused or neglected.
• For curiosity.
• Other.
• I don't know.
• I don't self harm.

How do you self harm?

Please select all that apply.

• Cutting.
• Burning.
• Scratching.
• Bruising.
• Headbanging
• Punching/Hitting.
• Picking skin or other body parts.
• Picking scabs or interfering with healing of wounds.
• Overdose/Substance abuse.
• Biting nails.
• Amputation/Enucleation/Others
• Eating disorders.
• Swallowing poisons or objects.
• Breaking bones.
• Staying in abusive relationships.
• Stragulation.
• Pulling hair.
• Biting skin/fingers/lips/others.
• Putting salt and ice on skin.
• Sticking things into skin/body.
• Excessive body piercing or tattooing
• Excessive exercise.
• Starvation.
• Rubber band snapping.
• Taking unnecessary risks.
• Other. (you can tell in comments)
• I don't self harm.

Do you want to stop self harming?

• Yes.
• I already did.
• Not right now.
• No/Never.
• I don't self harm.

Do you regret starting self harming?

• Yes.
• Sometimes.
• Never.
• I don't self harm.

Do you hide your self harm?

• Yes.
• Sometimes.
• No.
• I don't self harm.

Somebody ever found out that you self harm?

• Yes, a lot of people/everybody knows.
• Yes, a few persons.
• No one.
• I don't self harm.

Do you use:

Please select all that apply.

• The Butterfly Project?
• The Paper Chain Project?
• Other. (you can tell in comments).
• None of the above.
• I don't self harm.