Self-Injury: A Struggle

This is a survey that is completely anonymous, you do not have to reveal your name or e-mail address unless you choose to do so in the "Comments" area of the survey. You don't have to answer any question that makes you uncomfortable or that you just don't know. Thank you everyone who chooses to share their story for their courage; and be proud of yourself!

Self-Injury Survey

1. Gender:
A. female
B. male
C. other

2. Sexual Orientation:
A. heterosexual
B. gay/lesbian
C. bisexual
D. asexual

3. Job/School (i.e. high school student, doctor, etc.)

4. How old are you currently?

5. How old were you when you first SI-ed?

6. Why do you SI?

7. What is your main method of SI (cutting, burning, hitting, etc.)? Do you have any others?

8. Do you feel pain when you SI? Or have you dissociated?

9. How do you feel before, during, and after you SI?

10. Do you have any rituals?

11. Have you ever SI-ed in front of anyone? Have you ever been caught?

12. Do you anybody who SI's (friend, family member, etc)? Did they have any influence on your own behavior?

13. How do you hide your SI?

14. Have you ever told anyone you SI? If yes, then who?

15. How did they react and what did you feel?

16. Why did you tell? If you haven't told anyone, why not?

17. Since you've told has living with your SI been easier or more difficult? If you haven't told how do think things would change if you did?

19. Do you have any coping skills (methods) that help stop you from SI-ing? If so, what are they?

20. Have you ever gotten any medical attention for your injuries? What were the attitudes you encountered from medical professionals?

21. Have you ever gone into therapy to treat your self-injurious behavior? Have you ever gone in-patient at a psychiatric hospital because of your self-injury or for any mental illnesses that cause you to self-injure?

22. Do you take any medication for your SI or for any mental illness that causes you to self-injure? If yes, which medication?

23. Have you ever been refused therapy or lost a psychologist because of your SI?

Other:

25. Have you ever suffered any abuse (emotional, physical, sexual)? (Note: If you don't feel comfortable you have the choice not to answer the question)

26. Comments? Would you like to describe any aspect of self-injury? Feel free to put whatever you think or feel, etc. down.

27. Do you want any of this information to be put down in my "In Their Own Words..." page or in my upcoming self-injury book?
Yes, in both.
Yes, but only in the "In Their Own Words..." page.
Yes, but only in the upcoming self-injury book.
No

Leave out (insert whatever you part you don't want shared):

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Self-Injury Survey

Self-Injury Survey

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