Borderline Survey

Borderline Survey

Living with borderline personality disorder
1. General information:
Full Name

First NameLast Name
Nickname:
What do you want us to call you, dear borderline?
Age:*
2. Your Current Emotional State:
How are you feeling right now?*

0 = calm/ stable10 = overwhelmed / emotional crisis1-9 = In-between
Describe your main emotion at the moment:*

😞 Sadness😡 Anger😰 Anxiety😩 Emotional emptiness😵‍💫 Confusion🤍 Love / strong attachment😐 I’m not sure / mixed emotions
Want to share more?
🌪️ 3. Your Triggers:
What impacts you the most in general? (multiple choices)

Rejection (real or perceived)AbandonmentConflictsCriticismSilence / no replyAcademic / work stressBreakups / relationship fightsMemories / traumaI’m not sure yet
💛 4. What Helps You Calm Down:
Which techniques work for you?

Listening to musicWritingSleepingTalking to someoneGoing for a walkTaking a cold showerNothing really works
🤝 5. Your Relationship With Others:
Do you feel supported by the people around you?

Yes, a littleYes, a lotNot reallyNot at all
Would you like someone to contact you to offer help?

YesNo
Email (If yes):
6. Your Diagnosis (optional & anonymous):
Do you have a borderline personality disorder diagnosis?

Yes, official diagnosisIn progressI think I have itNot sure
🎨 7. Your Goal:
What are you looking for on this platform?

Emotion regulation toolsA mood trackerA journal spaceA safe communityResources to understand BPDHelp with my relationshipsI’m exploring / just looking around
8. Personal Safety:

(sensitive but necessary; must stay private and secure)
Have you experienced suicidal thoughts recently?

YesSometimesNoPrefer not to answer
Are you safe right now?

YesNot completelyNo / I need help
9. Consent & Privacy:
I agree that my data may be used to improve my experience on the platform.

YesNo
Should be Empty: