SBQ

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 year (4 digits)
Name of therapist (primary therapist)
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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?

If so, when was the last time you did this?
I did not
in the last 7 days
in the last 14 days
in the last 30 days
in the last 2 months
2 - 4 months ago
5 - 8 months ago
over 8 months ago

Within the last month, have you thought about or attempted to kill yourself?
No
It was just brief passing thoughts
I had a plan at least once to kill myself, but did not try to do it
I had a plan at least once to kill myself, and really wanted to die
I attempted to kill myself, but did not want to die
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?

If so, when was the last time?

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


Within the last month, have you told someone that you were going to commit suicide, or that you might do it?
No
Yes, at one time, but did not really want to die
Yes, at one time, and really wanted to die
Yes, more than once, but did not want to do it
Yes, more than once, and really wanted to do it

How likely is it that you will attempt suicide some day?


Do you currently have a plan for how you would go about killing yourself, if you decided 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?
Never, 0 times in the last week
Rarely, 1-2 times in the last week
Occasionally, 3-4 times in the last week
Sometimes, 5-10 times in the last week, or 1-2 times a day
Often, 11-20 times in the last week, or 2-3 times a day
Most of the time, 20-40 times in the last week, or 3-6 times a day
Nearly all of the time, more that 40 times in the last week, or more than 6 times a day

At the most severe point, how strong was your urge to self-injure in the last week?
None at all
Slight, that is, a very mild urge
Mild Urge
Moderate Urge
Strong Urge, but easily controlled
Strong Urge, but difficult to control
Strong Urge and would have self-injured if able to

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


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


Keeping in mind your responses to the previous questions, please rate your overall average urge or desire to injure yourself in the last week.
Never thought about it and never had the urge to self-injure
Rarely thought about it and rarely had the urge to self-injure
Occasionally thought about it and occasionally had the urge to self-injure
Sometimes thought about it and sometimes had the urge to self-injure
Often thought about it and often had the urge to self-injure
Thought about self-injury most of the time and had the urge to do it most of the time
Thought about self-injury nearly all the time and had the urge to do it nearly all the time