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 ([email protected]) 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.
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