Self harm survey template helps clinicians, therapists, and researchers gather information about individuals' experiences, awareness, and attitudes toward self-harm. This free template is designed for sensitive, confidential data collection and can be customized to suit clinical assessments, intake screenings, or research.

The form includes multiple-choice items on when and where respondents first learned about self-harm, whether they have self-harmed, age at first incident, and whether peers engage in self-harm. It also asks what topics respondents want to learn more about, their age bracket, and offers open fields for advice and brief personal stories to share insights with others.

Optional name and email fields allow follow-up while preserving anonymity for those who prefer not to identify themselves. The template is suitable for therapists, school counselors, mental health clinics, research projects, and support organizations seeking compassionate, structured feedback.

Click "Use This Template" to customize this free template and publish a respectful questionnaire.