Check off all that you have experienced.

Place a question mark if you are unsure.

Feel free to add to the list anything that doesn’t fit into the categories.

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[x]Fears of abandonment

[x]Sexual violation

[x]Verbal abuse

[ ]Phyiscal Abuse

[x]Sexual abuse

[x]Bullying

[x]Self-hate

[x]Self-Harm: Cutting

[ ]Self- Harm: Burning

[x]Self-Harm: Hitting

[x]Suicidal thoughts

[ ]Attempted suicide

[ ]One biological parent was absent from the majority of your life

[ ]You lived in a split household

[ ]You were adopted

[ ]You had a serious childhood illness

[x]You have undergone mental trauma

[x]Your family fought 

[ ]Your grew up in an improverished area

[ ]Your family was in poverty when you were a child

[x]You have/had/are recovering from an eating disorders

[x]You’ve looked at thinspo in order to motivate you to lose weight

[x]You’ve tried starving yourself

[x]You are/were an alcoholic.

[ ]You have/had a sexual addiction.

[x]You have/had a self-harm addiction.

[x]You have/had a different addiction.

[x]You have had no friends at one point in your life.

[x]You’ve been lonely.

[ ]You feel alone in the world.

[XXXXX]You have social anxiety.

[x]You’ve experienced disociation.

[ ]You have a diagnosed disociative disorder.

[x]You may have an undiagnosed disociative disorder.

[x]You’ve tried drugs.

[ ]You’ve never drank.

[ ]You’ll never drink.

[x]You drink occasionally.

[ ]You drink socially.

[ ]You drink seriously.

[ ]You smoke.

[ ]You chew tobacco.

[x]You have a diagnosed personality disorder.

[ ]You may have an undiagnosed personality disorder.

[x]You have phobias.

[ ]You may have undiagnosed phobias.

[x]You have/had depression.

[ ]You feel you have anger problems.

[x]You have seen a therapist/counselor.

[x]You have a hard time trusting others.

[x]You’ve been in a minor car accident.

[ ]You’ve been in a serious car accident.

[]You are Christian.

[ ]You are Muslim.

[ ]You are Jewish.

[ ]You are Wiccan.

[ ]You are another religion.

[x]You are agnostic.

[ ]You are atheist.