Self-Harm Questionnaire

Is your loved one alone a lot?

Has there been a recent change in your loved one’s behavior?

Is your loved one wearing inappropriate clothing with regards to the weather (e.g., long sleeves on a hot summer day)?

Does your loved one seem to be having a lot of accidents lately?

Has there been a recent change in your loved one’s family?

Are there high demands being placed on your loved one at school or at work?

Is your loved one under an increased amount of stress?

Does your loved one disappear for a long time after an argument, fight, or emotional confrontation?

Was your loved one ever victimized, physically or sexually, by an adult?

Has your loved one ever had a problem with his/her eating habits?

Has your loved one ever had a problem with alcohol or drugs?

If you answered “yes” to five or more of these questions, your son/daughter may be at risk for engaging in self-injurious behavior. Please call a therapist.

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