Self-Injury Survey "*" indicates required fields Survey QuestionsOptional Questions The self-injury survey explores times when you’ve hurt yourself on purpose without wanting to die, doing something that causes immediate pain or physical injury like cutting, burning, or scratching your skin. Please note: This test is experimental for self-harm. Your responses will help us improve the test for other people like you.Have you ever hurt yourself (engaged in self-injury) on purpose?* Yes No Your history with self-injuryHow old were you when you first engaged in self-injury?* Less than 10 years old 10-12 years old 13-15 years old 16-17 years old 18 years or older If you had to estimate, how often would you say that your injuries resulted in permanent scars?* Never Sometimes About half the time Most times Always In the last year, have you engaged in self-injury on 5 or more days?* Yes No In the following questions, please think about your self-injury behaviors in the past month (30 days). In the past month (30 days), on how many days have you engaged in self-injury?*-+Please enter a number from 0 to 30.In the past month, how often have you had an urge (or a strong desire) to injure yourself?* Never Once or twice during the past 30 days Around once a week Several times a week Several times a day Prefer not to answer In the past month, how often have you injured yourself so badly you weren’t sure you could care for your wounds without help?* Never Sometimes About half the time Most times Always Prefer not to answer In the past month, how often did you have negative feelings or thoughts (anger, sadness, self-criticism, etc.) before injuring yourself?* Never Sometimes About half the time Most times Always Prefer not to answer In the past month, how often were you thinking or worrying about the idea of injuring yourself before injuring yourself?* Never Sometimes About half the time Most times Always Prefer not to answer In the past month, how often have you experienced conflict or problems with other people before injuring yourself?* Never Sometimes About half the time Most times Always Prefer not to answer In the past month, how often have you had thoughts of killing yourself or ending your life?* Never Once or twice during the past 30 days Around once a week Several times a week Several times a day Prefer not to answer If you need immediate help, you can reach the Suicide & Crisis Lifeline by calling or texting 988 or using the chat box at 988lifeline.org. You can also text “MHA” to 741-741 to reach the Crisis Text Line. Warmlines are an excellent place for non-crisis support. When thinking about your self-injury in the past month, please rate how much you agree or disagree with these statements. Please rate how much you agree or disagree with these statements. When I injure myself, I expect it will stop or relieve bad feelings or thoughts.* Strongly Agree Agree Unsure Disagree Strongly Disagree When I injure myself, I expect it will make me feel good, or better than I do.* Strongly Agree Agree Unsure Disagree Strongly Disagree When I injure myself, I expect it will help me resolve problems with others.* Strongly Agree Agree Unsure Disagree Strongly Disagree Over time, I have had to injure myself more deeply or in more places to get the same effect.* Strongly Agree Agree Unsure Disagree Strongly Disagree Self-injury has affected relationships that are important to me.* Strongly Agree Agree Unsure Disagree Strongly Disagree Self-injury has affected my ability to do school work or finish work tasks.* Strongly Agree Agree Unsure Disagree Strongly Disagree Self-injury has affected my ability to take care of myself.* Strongly Agree Agree Unsure Disagree Strongly Disagree Self-injury has affected my ability to do things that I like.* Strongly Agree Agree Unsure Disagree Strongly Disagree Please take a moment to answer the following optional questions. Your answers are totally anonymous—we won't be able to identify you based on this information. Your answers help us provide better information and support for people like you. You can answer as many or as few questions as you would like. When you are done, scroll to the bottom of the survey and click "submit" to receive your screening results.Are you taking this test for yourself or for someone else? For myself For someone else If you are taking this test for someone else, please use that person's information for the questions below, or leave them blank if you don't know the answer. Remember, these questions are optional.About YouAge Range8-1011-1314-1516-1718-2425-3435-4445-5455-6465+Gender Female Male Non-Binary How would you describe your gender?Please check this box if you identify as transgender. Please check this box if you identify as transgender. Race/EthnicityAmerican Indian or Alaska NativeAsianBlack or African American (non-Hispanic)Hispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or other Pacific IslanderWhite (non-Hispanic)More than one of the aboveOtherHousehold IncomeLess than $20,000$20,000 - $39,999$40,000 - $59,999$60,000 - $79,999$80,000 - $99,999$100,000 - $149,999$150,000+Do you live in the United States or another country? I live in the United States I live in another country StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingI live in a U.S. TerritoryWhat country do you live in?AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsZip/Postal CodeWhich of the following populations describes you?Select all that apply. Veteran or active-duty military Caregiver of someone living with emotional or physical illness LGBTQ+ Student Trauma survivor New or expecting parent Healthcare worker Are you caring for someone with a mental or physical health condition? Mental health condition Physical health condition Both mental and physical health conditions Which of the following best describes your sexual orientation?Lesbian or GayBisexualQueerPansexualAsexualStraightOther...What is your sexual orientation?Which of the following describe your experience of trauma?Select all that apply. Child abuse/violence Intimate partner violence Sexual assault/violence Serious illness/injury/assault Family conflict (identity acceptance/separation/divorce) Traumatic event (natural disaster, accident, witnessing violence, etc.) Death of a loved one Other and/or tell us more about your trauma Please tell us more about your experience of trauma:About Your Mental HealthHave you ever received treatment/support for a mental health problem? Yes No Are you receiving treatment/support now? Yes No Think about your mental health test. What are the main things contributing to your mental health problems right now?Choose up to 3. Abuse or violence Relationship problems (friends, family, or significant other) Body image Low self-esteem or self-image School or work problems Financial problems Loneliness or isolation Grief or loss of someone or something Experiencing hate/bullying (including racism, homophobia, transphobia, or discrimination) State of the world (war, climate, politics) I don’t know (something just feels wrong) Other... What else is contributing to your mental health problems right now?What about the state of the world is affecting you the most?About Your HealthDo you currently have health insurance? Yes No Do you have any of the following physical health conditions?Select all that apply. Heart disease Reproductive health concerns (PCOS, endometriosis, infertility, etc.) Diabetes Cancer Arthritis or other chronic pain Asthma, COPD or other lung conditions Movement Disorders (involuntary tics, tardive dyskinesia, etc.) Digestive problems (Crohn’s, colitis, IBS, etc.) Neurological conditions (epilepsy, etc.) or traumatic brain injury (TBI) Other... What other physical health conditions do you have?EmailThis field is for validation purposes and should be left unchanged.
