This free survey is powered by
0%
Exit Survey
 
 
Hello: Thank you for taking time to participate in my survey on suicide. The purpose of the survey is to collect data for the book I'm writing on Suicide an Epidemic in America. The book is being written to help bring awareness to the epidemic at hand. The desire was put in me to help bring people out of darkness into the light. My goal is to shed light where there is no light, bring hope where there is no hope, and show love where there is no love. 
Your participation in this study is completely voluntary. If you feel uncomfortable answering any questions, you can withdraw from the survey at any point. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 
 
 
 
Have you ever attempted suicide?
 
Yes
 
No
 
 
 
How did or do you want to hurt self?
   
 
 
 
Have you ever felt (Select all that apply)?
 
Depressed
 
Sad
 
Anxious
 
Worthless
 
Unloved
 
Broken on the inside
 
Like no one understands you
 
Hopeless

 
 
 
What does suicide mean to you?
   
 
 
 
Do you have a means to hurt self? if yes what method
   
 
 
 
Is suicide your last resort? if yes what else have you tried?
   
 
 
 
Are there recent stressors in your life?
 
Job loss
 
Eviction
 
Family Problems
 
Substance use
 
Homeless
 
Finance Problems
 
Abuse (physical or mental)
 
Care taker for mentally challenged or disabled child
 
Care taker for elderly parent /grandparent
 
Disappointment
 
Hurt

 
 
 
Tell me your story
   
 
 
 
Gender
 
Male
 
Female
 
 
 
Location
 
Midwest region
 
South region
 
East region
 
West region
 
Canada
 
Mexico
 
 
 
Age range
 
5-9
 
10-14
 
15-19
 
20-24
 
25-29
 
30-34
 
35-39
 
40-44
 
45-49
 
50-54
 
55-59
 
60-64
 
65-69
 
70+

 
Share This Survey:          Surveys Powered by  QuestionPro Survey Software