Preliminary NSSI Questionnaire for School Counselors

Directions: Please fill out the following preliminary questionnaire. After submitting the form, you'll be asked to watch the online presentation on self-injury. At the end of the presentation, you'll be asked to fill out an abbreviated version of this questionnaire as a post-presentation assessment.

For the purpose of this questionnaire, Non-suicidal self-injury (NSSI) does not include the use alcohol or drugs. The term “counseling”, as defined by ASCA, refers to “meeting with students to assist them in resolving or constructively managing their problems.” This does not involve providing treatment.

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    Participating in abuse of or addiction to alcohol or other mind-altering chemicals
    Participating in behavior associated with eating disorders (i.e. binging/purging, witholding food intake, compulsive overeating)
    Experiencing emotional abuse from a parent or significant other
    Experiencing physical abuse from parent or significant other
    Experiencing sexual abuse from a parent or significant other
    Living in a foster home
    Experiencing a sense of relief after committing Serious Bodily Injury
    Experience a sense of disassociation after committing Serious Bodily Injury
    Feeling a sense of self-punishment when committing Serious Bodily Injury
    Attempting suicide on at least one occasion
    Learning of Serious Bodily Injury while observing another student
    Please enter one response per row