1. How old were you when you started self-harming?
•Younger than 4
•4-5
•6-7
•8-9
•10-11
•12-13
•14-15
•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
•I am trying to stop again
3. What method of self-harm do/did you primarily use?
•Cutting
•Burning
•Hair-pulling
•Scratching and picking at skin until blood flows
•Interference with the healing of wounds
•Hitting or bruising
•Snapping Rubber Bands
•Digging Nails Into Skin
•Bone breaking
•Writing/Carving on self
•Cutting and Burning
4. If you self-harm what sexual orientation are you?
•Straight Male
•Straight Female
•Bi-Sexual Male
•Bi-Sexual Female
•Homosexual Male
•Homosexual Female
•Transgender Male
•Transgender Female
•Questioning Male
•Questioning Female
•Pan-sexual Male
•Pan-Sexual Female
•Prefer not to answer
5. Which of these, if any, were something you struggle with along with self-harm?
•Anorexia
•Bulimia
•ED-NOS
•Anorexia and Bulimia
•Suicidal Ideation
•Various Psychiatric Disorders (GAD, Depression, etc.)
•Learning Disabilities
•A Mixture of the Above
•None of the Above
•I don’t have a clue.
6. Do you think that you (as an individual) need professional help to stop self-harming?
