Hi, I'm Rachel.

  1. Check off all that you have experienced.
  2. Place a question mark if you are unsure.

[x] Fears of abandonment.
[] Sexual violation.
[x] Verbal abuse.
[] Physical Abuse.
[] Sexual abuse.
[x] Bullying.
[x] Self-hate.
[x] Self-Harm: Cutting.
[] Self- Harm: Burning.
[] Self-Harm: Hitting.
[x] Suicidal thoughts.
[x] Attempted suicide.
[x] One biological parent was absent from the majority of your life.
[x] 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 impoverished area.
[] Your family was in poverty when you were a child.
[x] You have/had/are recovering from an eating disorders.
[X] You’ve tried starving yourself.
[] You are/were an alcoholic.
[] You have/had a sexual addiction.
[X] You have/had a self-harm addiction.
[]You have/had a different addiction.
[X] You have had no friends at one point in your life.
[X] You’ve been lonely.
[X] You feel alone in the world.
[X] You have social anxiety.
[] You’ve experienced dissociation.
[] You have a diagnosed dissociative disorder.
[] You may have an undiagnosed disociative disorder.
[] You’ve tried drugs.
[] You’ve never drank.
[] You’ll never drink.
[] You drink occasionally.
[X] You drink socially.
[] You drink seriously.
[] You smoke.
[] You chew tobacco.
[] You have a diagnosed personality disorder.
[X] You may have an undiagnosed personality disorder.
[X] You have phobias.
[x] You may have undiagnosed phobias.
[X] You have/had depression.
[X] 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.
[] You are agnostic.
[?] You are atheist.

82 notes - 20 February, 2012