Call today: (616) 719-0194

Questionnaire- Self Injury

SELF-INJURY SELF ASSESSMENT*

1. I was often told as a child that I had to be strong. True____ False____

2. I do not remember much affection being displayed in my family. True____ False____

3. Anger was the feeling most often displayed in my family. True____ False____

4. I rarely felt I could express my feelings to my family. True____ False____

5. As a child I remember my mother and/or father as overly intrusive. True____ False____

6. As a child I remember being sexually abused. True____ False____

7. As a child I remember being physically abused. True____ False____

8. As a child I remember being emotionally abuse. True____ False____

9. As a child my mother and/or father was emotionally absent. True____ False____

10. I remember times when I was punished for strong feelings. True____ False____

11. When I was upset or frightened, I was ignored. True____ False____

12. I grew up in a very religious household. True____ False____

13. I had a parent who was unable to raise me due to a physical illness or trauma. True____ False____

14. I grew up with a lot of double messages. True____ False____

15. I often think of myself as a “bad” person. True____ False____

16. I often believe that I’m at fault for everything that goes wrong. True____ False____

17. I often think that everyone would be happier if I were dead. True____ False____

18. I hate change. True____ False____

19. I seem to have an all-or-nothing attitude. True____ False____

20. I usually can’t find words that explain how I feel. True____ False____

21. I am a perfectionist. True____ False____

22. I think I am a burden to others. True____ False____

23. I do not want to die; I just want to stop my emotional pain. True____ False____

24. My friends and family have become concerned about my body piercing. True____ False____

25. I have decided to continue piercing despite the fact that one or

more significant others have told me that they are repulsed by it. True____ False____

26. I become anxious when anyone tries to stop me or prevent me from getting a

new piercing. True____ False____

27. I have problems with drugs or alcohol. True____ False____

28. I have sometimes neglected to seek medical attention for an

illness or injury when part of me knows that I should have. True____ False____

29. I have an eating disorder, or have had one sometime in the past. True____ False____

30. I have – or have had- a tendency to be promiscuous. True____ False____

31. I have overdosed on drugs. True____ False____

32. I often obsess about self-injury. True____ False____

33. I sometimes can’t explain where my injuries come from. True____ False____

34. I get anxious when my wounds start to heal. True____ False____

35. I often believe that if I don’t self-injure, I’ll go “crazy.” True____ False____

36. No one can hurt me more than I can hurt myself. True____ False___

37. I can’t imagine life without self-injury. True____ False____

38. If I stop self-injuring, my parents win. True____ False____

39. I often self-injure as a way to punish myself. True____ False____

40. Self-injury is my best friend. True____ False____

41. I consider my tendency to self-harm an addiction. True____ False____

42. Many times I harm myself more out of habit than for any specific

reason. True____ False____

43. I have self-injured: Only once__ 2-5 times__ 6-10 times__11-20 times__ 21-50 times__

More than 50 times__

44. When did you last harm yourself? Within the past 6 weeks__ Past six months__ Past year__

More than one year ago__?

Questions 1-14

The more questions you answered “true”, the more likely it is that your early experiences were similar to those described by self-injurers.

Questions 15-23

The more questions you answered “true” in this section, the more your view of yourself matches the views commonly expressed by self-injurers.

Questions 24-31

If you answered “true” to any of these questions, it may signal that you have a serious problem with self-injury.

Questions 32-44

We suggest that anyone who answered “true” to any of these questions might benefit from consultation with a professional who understands self-injury. You may use the questionnaire as a tool for discussion during the consultation.

If would like to speak with someone from Adolescent & Family Behavioral Health Services, please mail or email (vlagnew@comcast.net) this information.  To set an appointment with me click here.

Name _______________________________________________________________

Address (street, city, state, zip) _______________________________________________________________

Phone Number: _________________ Email Address ________________________

Best time to reach you_____________________

Mail to: Adolescent & Family Behavioral Health Services

             3501 Lake Eastbrook Blvd SE, Suite 258

             Grand Rapids, MI 49546

This assessment is based on the clinical experience of S.A.F.E. ALTERNATIVES and not research.  It is meant to be used as a tool for self evaluation and not intended to diagnose.  You must meet with a clinical therapist for evaluation to be diagnosed.  Mailing the assessment does not constitute a therapeutic relationship.

® 800-DONTCUT® (366-8288) self injury.com  S.A.F.E. ALTERNATIVES