Self-harm/Self-Injury Screening Questionaire

You can print this page and answer the questions in privacy by answering "true" only to the statements you agree with. If the results indicate that you may have a problem with self-injury, we recommend that you bring the results to your family doctor for further assessment and/or contact one of our counsellors if you wish to explore therapeutic options.

  1. I was often told as a child that I had to be strong.
  2. I do not remember much affection being displayed in my family.
  3. Anger was the feeling most often displayed in my family.
  4. I rarely felt I could express my feelings to my family.
  5. As a child I remember my mother and/or father as overly intrusive.
  6. As a child I remember being sexually abused.
  7. As a child I remember being physically abused.
  8. As a child I remember being emotionally abused.
  9. As a child my mother and/or father was emotionally absent.
  10. I remember times when I was punished for strong feelings.
  11. When I was upset or frightened, I was ignored.
  12. I grew up in a very religious household.
  13. I had a parent who was unable to raise me due to a physical illness/trauma.
  14. I grew up with a lot of double messages.
  15. I often think of myself as a "bad" person.
  16. I often believe that I’m at fault for everything that goes wrong .
  17. I often think that everyone would be happier if I were dead.
  18. I hate change.
  19. I seem to have an all-or-nothing attitude,
  20. I usually can't find words that explain how I feel.
  21. I am a perfectionist.
  22. I think I am a burden to others.
  23. I do not want to die; I just want to stop my emotional pain.
  24. My friends and family have become concerned about my body piercing.
  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.
  26. I become anxious when anyone tries to stop me or prevent me from getting a new piercing.
  27. I have problems with drugs or alcohol.
  28. I have sometimes neglected to seek medical attention for an illness or injury when part of me knows that I should have.
  29. I have an eating disorder, or have had one sometime in the past.
  30. I have - or have had - a tendency to be promiscuous.
  31. I have overdosed on drugs.
  32. I often obsess about self-injury.
  33. I sometimes can't explain where my injuries come from.
  34. I get anxious when my wounds start to heal.
  35. I often believe that if I don’t self-injure, I’ll go "crazy."
  36. No one can hurt me more than I can hurt myself.
  37. I can't imagine life without self-injury.
  38. If I stop self-injuring, my parents win.
  39. I often self-injure as a way to punish myself.
  40. Self-injury is my best friend.
  41. I consider my tendency to self-harm an addiction.
  42. Many times I harm myself more out of habit than for any specific reason.
  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 week__Past month__ Past six months__ Past year__ More than one year ago__

Interpretation of Total Score

Questions 1-14

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

Questions 15-23

The more questions you answered true in this section, the more your view of yourself matches the views commonly expressed by those who self-harm.

Questions 24-31

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

Questions 32-42

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

Disclaimer:

This is only a preliminary screening test for self-harm that does not replace in any way a formal evaluation. It is designed to give a preliminary idea about the presence of mild to moderate self-harm symptoms that indicate the need for an evaluation by a professional knowledgeable about self-harm. This screening tool created by S.A.F.E. Alternatives.