How old were you when you first started self harming?

[] Younger than 4
[] 5-6
[] 6-7
[] 7-8
[x] 9-10
[] 10-11
[] 11-12
[] 12-13
[] 13-14
[] 14-15
[] 15-16
[] 16-17
[] 17-18
[] 18-19
[] 19-20
[] Older than 21

How often do you self harm?

[] Depends on what mood I’m in
[] More than once a day
[] Every day
[] Once a week
[] Two or more times a month
[] A few times a year
[] I’m trying to stop
[x] I’ve stopped

What form of self harm do/did you use?

[x] Cutting
[x] Burning
[] Hair pulling
[] Scratching
[] Interference with healing of wounds
[x] Hitting or bruising
[x] Bone breaking
[] Cutting and Scratching
[x] Cutting and Burning
[x] Hitting head against walls
[x] Binging
[x] Purging
[x] Starving
[x] Biting
[] Rubber band slaps

If you self harm what sexual orientation are you?

[] Straight Male
[] Straight Female
[] Bi-sexual Male
[] Bi-sexual Female
[] A-sexual Male
[] A-sexual Female
[x] Homosexual Male
[] Homosexual Female
[] Transgender Male(FtM)
[] Transgender Female(MtF)
[] Questioning Male
[] Questining Female
[] Pan-sexual Male
[] Pan-sexual Female
[] Demi-sexual Female

Which of these,if any,are something you struggled with along with self harm?

[] Anorexia
[] Bulimia
[x] Anorexia and Bulimia
[] EDNOS
[x] Suicidal ideation
[] Various Psychiatric Disorders
[] Learning Disabilities
[] None of the above

Do you think you need professional help to stop self harming?

[] Yes, the only way i could stop is with professional help.
[x] No, I have stopped on my own
[] No,i have stopped on my own but i still have trouble and mess up sometimes.
[] No, I have no desire to stop therefore i don’t need professional help
[] Yes, I have stopped with professional help
[] I don’t think i could ever stop without professional help
[] Prefer not to answer
[] I don’t know

Are you trying to stop self harming?

[] No, and i dont want to stop
[] No,but i would like to be able to stop
[] Yes,but im not doing very well
[] I have stopped but i mess up every once in a while
[x] I am self harm free

Does anyone know about your self harm?

[] No. No one knows.
[] Some peolple may have a vague idea of something
[] Yes. But only my closest friend(s)
[] Yes. But only my closest family member(s)
[x] Yes. Some friends and family.
[] Yes, most of (or all of) my friends.
[] Yes, most of (or all of) my family.
[] Yes,people that see my scars/cuts
[] Yes,a few people that i really trust.
[] Yes,my therapist/counselor/psychiatrist

How many years have you been self harming?

[] One or less years
[] 2 years
[] 3 years (almost 4)
[] 4 years
[] 5 years
[x] 6 years
[] 7 years
[] 8 years
[] 9 years
[] 10 or more years

If you self harm were you abused or neglected as a child or later on in life?

[] No(don't think so)
[] Yes,emotionally abused
[] Yes,physically abused
[] Yes,sexually abused
[] Yes, I was emotionally and physically abused
[] Yes, I was physically and sexually abused
[x] Yes,I was emotionally and sexually abused [by people in psychiatric hospitals]
[] Yes,I was physically,emotionally,and sexually abused
[] Yes,I was neglected
[] Yes,i was neglected and abused
[] Prefer not to answer

Would you label yourself as emo?

[] Yes
[x] No
[] I guess

Do others label you as emo?

[x] Yes
[] No
[] I dont know

What do you label yourself as?

[] Prep
[] Goth
[] Emo
[] Punk
[] Nerd
[] Hipster
[] Pothead
[] Poser
[] Skater
[] Druggie
[] Normal
[] I dont know
[x] I dont believe in labels

How do you react when you see others self harm scars/marks?

[x] I want to get to know them
[] I want to know what they went through in order to see that as a way out
[] I want to get as far as possible from them so no one knows about my self harm
[x] I consider them as someone who shares something in common with me
[] I would never acknowledge them
[] What happened for them to start self harming
[ ] Fear
[ ] Interest
[x ] Sadness
[] Hapiness
[] Dont really care
[] No reaction
[] Surprise
[] Relief
[] Jealousy
[] Happy that no one cuts as bad as me
[] Upset that no one cuts as bad as me