SBQ-R

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

SBQ-R

Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.

Birthday *

YYYY

Name *

Since your first therapy session at DBT San Diego, have you deliberately hurt yourself physically (such as cut or burned yourself), but were not trying or expecting to die? *

0 - I did not

1 - Yes, on 1 day

2 - Yes, on 2-4 days

5 - Yes, on 5-10 days

10 - Yes, on more than 10 days

If you answered yes to the previous question: When was the last time you did this?

0 - I did not

7 - In the last 7 days

14 - In the last 14 days

30 - In the last 30 days

60 - In the last 2 months

120 - 2-4 months ago

200 - 5-8 months ago

240 - Over 8 months ago

Clear selection

Within the last month, have you thought about or attempted to kill yourself? *

0 - No

1 - It was just passing thoughts

2 - I had a plan at least once to kill myself, but did not try to do it

3 - I had a plan to kill myself at least once, and really wanted to die

4 - I attempted to kill myself but did not want to die

5 - I attempted to kill myself, and really hoped to die

Since your first DBT session, have you gone to a hospital emergency room or been admitted to a psychiatric hospital because of suicidal behavior or ideation, or self-injury? *

Yes, 1 time

Yes, 2 times

Yes, more than 2 times

If you answered yes to the previous question: When was the last time?

I did not

This week

This month

2-4 months ago

5-8 months ago

Over 8 months ago

Clear selection

How often have you thought about killing yourself within the last month? *

0 - Never

1 - Rarely

2 - Sometimes (2 times)

3 - Often (3-4 times)

4 - Very often (4 or more times)

Within the last month, have you told someone that you were going to commit suicide, or that you might do it?

0 - No

1 - Yes, at one time, but did not really want to die

2 - Yes, at one time, and really wanted to die

3 - Yes, more than once, but did not want to do it

4 - Yes, more than once, and really wanted to do it

Clear selection

How likely is it that you will attempt suicide one day? *

0 - Never

1 - No chance at all

2 - Rather unlikely

3- Unlikely

4 - Likely

5 - Rather likely

6 - Very likely

Do you currently have a plan for how you would go about killing yourself, if you decided to do it? *

0 - No

1 - Yes, a vague plan

2 - Yes, a definite plan

3 - Yes, and I intend to do it

The questions below apply to the last week. Select the most appropriate statements.

How often have you thought about injuring yourself or about how you want to injure yourself?

0 - Never, 0 times in the last week

1 - Rarely, 1-2 times in the last week

2 - Occasionally, 3-4 times in the last week

3 - Sometimes, 5-10 times in the last week, or 1-2 times a day

4 - Often, 11-20 times in the last week, or 2-3 times a day

5 - Most of the time, 20-40 times in the last week, or 3-6 times a day

6 - Nearly all of the time, more that 40 times in the last week, or more than 6 times a day

Clear selection

At the most severe point, how strong was your urge to self-injure in the last week?

0 - None at all

1 - Slight, that is, a very mild urge

2 - Mild urge

3 - Moderate urge

4 - Strong Urge, but easily controlled

5 - Strong Urge, but difficult to control

6 - Strong Urge and would have self-injured if able to

Clear selection

How much time have you spent thinking about injuring yourself or about how you want to injure yourself?

0 - None

1 - Less than 20 min.

2 - 21-45 min.

3 - 46-90 min.

4 - 90 min to 3 hrs.

5 - 3-6 hrs.

6 - More than 6 hrs.

Clear selection

How difficult was it to resist injuring yourself in the last week?

0 - Not difficult at all

1 - Very mildly difficult

2 - Mildly difficult

4 - Moderately difficult

5 - Very difficult

6 - Extremely difficult

7 - Was not able to resist

Clear selection

Keeping in mind your responses to the previous questions, please rate your overall average urge or desire to injure yourself in the last week.

0 - Never thought about it and never had the urge to self-injure

1 - Rarely thought about it and rarely had the urge to self-injure

2 - Occasionally thought about it and occasionally had the urge to self-injure

3 - Sometimes thought about it and sometimes had the urge to self-injure

4 - Often thought about it and often had the urge to self-injure

5 - Thought about self-injury most of the time and had the urge to do it most of the time

6 - Thought about self-injury nearly all the time and had the urge to do it nearly all the time

Clear selection

Filled out by

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of DBT San Diego.

Does this form look suspicious? Report

Forms