The truth
1. How old were you when you started self-harming?
[] Younger than 4
[] 4-5
[] 6-7
[x] 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
[x] I am trying to stop (it varies depending on relapses)
3. What method of self-harm do/did you primarily use?
[x] Cutting
[]Burning
[]Hair-pulling
[x] Scratching
[x] Interference with the healing of wounds
[x] Hitting or bruising
[] Bone breaking
[]Cutting and Scratching
[]Cutting and Burning
[] Hitting Head against walls
[] Binging
[] Purging
[x] Starving
[] Biting
4. If You Self Harm What Sexual Orientation Are You?
[] Straight Male
[] Straight Female
[] Bi-Sexual Male
[x] Bi-Sexual Female
[] A-sexual female
[] A-sexual male
[] Homosexual Male
[] Homosexual Female
[] Transgender Male
[] Transgender Female
[] Questioning Male
[] Questioning Female
[] Pan-sexual
5. Which Of These, If Any, Are Something You Struggle With Along With Self-harm?
[]Anorex
[] Bulimia
[] Anorexia and Bulimia
[] EDNOS
[x]Suicidal
[x] Various Psychiatric Disorders (i.e. Bi-polar,Borderline Personality, OCD, Panic, Anxiety, PTSD, Dissociative, Impulse Control Etc.)
[] Learning Disabilities
[] 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
[x] 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
[x] I don’t think I could ever stop 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
[x] 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 Friend
[] Yes. But Only Some Of My Family Member(s)
[x]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
[x] Yes, People that see my scars.
[]Just a couple of people I trust
[] Yes, My Therapist, Psychiatrist, etc
9. How many years have you been self-harming?
[] Less than 1 year
[] 1-2 years
[] 2 years
[] 3 years
[]4 years
[]5 years
[] 6 years
[x] 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
[x] Yes, I Was Emotionally Abused
[x]Yes, I Was Physically Abused
[x]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
[x] Yes, I Was Emotionally, Physically And Sexually Abused
[x] Yes, I Was Neglected
[x] Yes, I Was Neglected As Well As Being Abused
11. Would you label yourself as emo?
[] Yes
[x] No
[] I guess..?
12. Do others label you as emo?
[] Yes
[x] No
[] Some People
[] I don’t know
13. What would you or others label you as? (chose all that apply)
[] Prep
[] Goth
[] Emo
[] Punk
[] Nerd
[] Hipster
[] Pothead
[] Poser
[] Skater
[] Druggie
[] Normal
[]Weird
[x] I don’t know
[] I don’t believe in labels
14. What is your reaction when you see other people’s self-harm scars/cuts/marks? (choose all that apply)
[x] I want to get to know them
[x] 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
[x] I will acknowledge them as someone who shares something in common with me
[] I would never even acknowledge them
[x] What happened for them to start cutting
[x] Fear
[x] Interest
[x] Sadness
[]Happiness
[] Don’t really care
[] No reaction
[x]surprised
[] Relief
[] Jealousy










