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My Ballot Box |
What gender are you?
Female
Male
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What is your age?
10-13
14-16
17-19
20-24
25-30
31-37
38-44
45-55
56-65
65 +
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Have you ever been hospitalized for depression or some other mental illness?
No, never.
No, but almost.
Yes, once.
Yes, twice.
Yes, three times.
Yes, more than six times.
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What do you use to self-injure?
I do not self-injure.
Scissors.
Razor blade.
Knife.
Lighter.
Matches.
Chemicals.
Pins or needles.
Other.
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How often do you drink alochol?
I never drink alcohol.
A few times a year.
Once a month.
Couple times a month.
Weekends.
Weekends & once a week.
Every other day.
Every day.
other.
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What medication do you take (the highest dose if you take more than one listed).
No, I have no been diagnosed.
No, I do not have a mental illness.
I take Lithium.
I take Effexor.
I take Prozac.
I take Welbutrin.
I take Depakote.
I take Tegretol.
I take something else.
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If you could erase the scars from self-mutilation, would you?
I don't self-injure.
I don't have scars.
No, I think they are beautiful.
No, I love them because they are a reminder of what I have survived.
Yes, they are ugly and embarassing.
Yes, they have caused problems in my life.
I'm not sure.
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If you could quit cutting right now, would you?
I don't self-injure.
I already quit.
No, I enjoy cutting.
No, it is the only thing that keeps me stable.
Not right now, but I would like to quit someday.
Yes, I would like to quit right now.
I'm not sure.
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What would you say is the biggest thing between you & getting better?
I am fine now.
My family.
My friends.
Relationship problems.
Self-image problems.
Religion problems.
Sexual problems.
Not listed here.
Not sure.
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Do you hate yourself?
Yes.
No.
In-between.
Unsure.
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