- Check off all that you have experienced.
- Place a question mark if you are unsure.
[x] Fears of abandonment.
 Sexual violation.
[x] Verbal abuse.
 Physical Abuse.
 Sexual abuse.
[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.