Asterix (truemaddeep411) wrote in bus_unites,

Under the link is a survey I have made about SI in order for research purposes. Moderators, if this is unallowed, please feel free to delete this post. Surveyors, some topics in the survey may be triggering and uncomfortable, please read the disclaimer before you continue. Thank you for your time.

Self Injury Survey

Disclaimer: this survey is on a strict volunteer basis where anonamosity is respected. There are topics in this survey that people may find triggering or uncomfortable, if you wish to continue this survey please feel free to skip any answers you do not wish to answer. Above all, I ask that you answer honestly in the hope that these results can help others. Those who fill out this survey are encouraged to elaborate on their answers to provide additional information. Any questions/concerns about this survey can be forwarded to

*Note: In this survey SI stands for self injure*

Your Age:

Your Gender:

Your Sexual Orientation:

Your Race:

Do you consider yourself someone who does/has engaged in self injury?

If NO: do you know of anyone who self injures and if so, how many people?

If YES: how do you self injure?

1. cutting

2. burning/abrasions

3. punching/hitting self

4. pulling out hair

5. scratching/picking/tearing skin

6. carving

7. branding

8. biting

9. overdosing on pills/poison/drugs

10. deliberately breaking bones

11. Other:

Do you disagree with any of the above?

Do you consider any of the following to be methods of self injury?

Excessive drug use, drinking too much alcohol, smoking too much, starving yourself, binge-eating or making yourself vomit/laxative use

Why do you think you engage in SI?

How old were you when you started to SI?

Where on your body do you SI?

Have you told your parents that you SI?

Have you told your partner/significant other that you SI? (if single or not applicable, please state)

Have you ever been to a professional (therapist, psychologist, councilor, ect) about your SI?

Have you ever been diagnosed with a mental disorder? (If yes, please clarify)

If yes, do you believe that is a factor to your SI?

If you have not been diagnosed, to you think you suffer from a mental disorder?

Have you ever considered suicide as an option?

Have you ever tried to commit suicide?

Do you see a link between suicide and SI?

Do you consider SI a coping-mechanism to cope with stress? If not, clarify

Do you SI for attention?

Have you ever used SI or threatened SI to manipulate a person/situation? Explain.

Do you consider your SI a secret?

Are you ashamed/embarrassed that you SI?

Do you SI to punish yourself?

Does SI make you feel 'alive'?

Do you hide evidence of your SI? (tools, scars, ect. please clarify)

Do you suffer/experienced any of the below:

depression (if yes and have been diagnosed, please clarify)

low self-esteem


eating disorder (if yes and have been diagnosed, please clarify)


emotional distress

loss of parent/relative/friend (is yes, clarify)

molestation/rape (please clarify)

parental divorce/separation

divorce/separation to spouse

physical abuse (clarify)

emotional abuse (clarify)




severe mood swings

unsociable behaviors

need for control


do you disagree with any of the above?

Have you ever been sexually abused?

If yes, do you think this relates to your SI?

When you SI do you find it calms you or engergizes you? Explain.

Do you ever not remember acts of SI? Explain.

What is the longest you've went without SI?

When are you more likely to SI?

Are you triggered by images or things you read? Explain.

Do you want to/have you tried to/have you stop self injuring?



Thank you

Please feel free to add aditional information as you see fit.

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