1. Do you depressed or upset/sad as often as____ many times a week: a. 0 days b. 1-2 day c. 3-4 days d. 5-6 days 7, actually, but you didn't give that option. 2. On a regular basic do your friends talk about hurting themselves? a. Yes b. no I don't have friends, anyway. lol 3. Do you physically hurt yourself? a. yes b. no 4. If answered "yes" to number 3, why do you hurt yourself? If "no" move on to question 5. I just do it when I get really anxious and can't calm down any other way. 5. Do you eat to comfort/cheer yourself up? a. Yes b. No 6. Does your family have a history of mental health issues? a. yes- little to none. b. yes- mild c. yes- many members d. no- none 7. Did you grow up in a unsafe neighborhood? a. yes b. no 8. Did you feel threaten a family member growing up? a. yes c. no 9. Were you sexual abused? a. yes b. no 10. Do you starve yourself? a. no I used to, but I stopped. b. yes, why 11. Did you grow up in a single parent home? a. yes b. no 12. Do you believe that you have an emotional issue? a. yes Yes, and I've been diagnosed with having them. b. no 13. Are you: a. gay Transgendered, too! b. straight c. bisexual d. asexual 14. Was a parent(s) an alcoholic? a. yes My Dad says he's an alcoholic, but he doesn't really act like one. b. no 15. Has a family member ever commit/attempted suicide? a. yes, they were closely related to me (parent, sibling) b. yes, they were a distant relative (cousin, aunt, grandparent etc) c. none But I have, if that counts.
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