Name *

Your name or what you want to be called if you remain anonymous.

First Name

Last Name

Dependency

How do you generally deal with uncomfortable feelings?

I am able to accept that I'm having the experience and I take responsibility to find healthy ways to meet my needs..

I depend on other people to meet my emotional needs, and don't take adequate care of myself otherwise.

I binge on indulgences to distract myself from my feelings.

Hurt

Maybe you had one or both parents absent growing up, maybe you were made fun of or bullied. Maybe you experienced the loss of loved ones, rejection, or failure. Addictive behaviors are a way of coping with being hurt. How aware are you of ways that you’ve been hurt in the past and how this pain affects you in the present?

I am aware ways I’ve been hurt and I am healing and growing.

I tend to be impulsive when I get triggered.

I still feel hurt, even resentful, and I am defensive about it.

Access

How quick and easy is it for you to give in to your cravings?

I proactively protect myself from any uneccessary access to temptations

I have access after I get through some weak barriers.

I set myself up for open and easy whenever I want.

5. Resistance

You’re feeling a lot of agitation inside and a strong urge to indulge. You try to convince yourself not to do it, but you’re struggling. How much do you struggle and oscilate in efforts to resist?

I am able to resist indulging when I choose to.

I sometimes struggle very hard to resist indulging but eventually give in.

I am hardly ever able to resist indulging in sexual activity even when I try, or I just don't care.

6. Self-Conflict

As you’re caught between your values and desires, it’s like your there is a war going on inside of you. You may try to suppress the side of you that likes it, but you are stuck in a cycle. You resist until you can’t anymore, and then indulge, then you resist again, and then you indulge. You are split and don’t know what to do. How much self-conflict are you suffering from?

I accept myself as I am and am still moving wholeheartedly forward in self-realization.

I should be different because I believe I’m not good enough.

I’m torn between two lives.

7. Rationalization

You want to do it, but avoid feeling bad, so you conveniently conjure a myriad of reasons why ‘I might as well do it because…’ How are you with this?

I take responsibility for my mistakes and seek to rectify them.

I rationalize to avoid feeling bad about my mistakes.

I rationalize to give myself permission to indulge anytime I want to.

8. Frequency

How often do you use porn, illicit sex, or drugs?

Never

On occasion.

Habitually on a regular basis or whenever I can

9. Duration

When long do you binge on porn, illicit sex, or drugs?

I spend no time on these things.

Long enough to ejaculate once or get intoxicated once.

I binge for a long time and may ejaculate or get intoxicated many times.

10. Severity *

You find an initial rush from porn, illicit sex, or drugs but over time it diminishes the more that you binge. You learn to compensate for your gradual desensitization by escalating to more hardcore forms of sex or drugs. When you use porn, illicit sex, or intoxication, what level of escalation are you at?

I am free from porn, illicit sex, and intoxication

I use softcore stuff and am not escalating

I use hardcore stuff or find myself escalating towards it

11. History

How long have you been using porn, illicit sex, or drugs?

I haven’t as a habit for any amount of time.

I have as a habit or when I can for a few years.

I have as a habit or when I can for over a decade.

12. Failure *

Maybe you are afraid of how you will feel if you wholeheartedly try to stop indulging but fail, so you don’t give it your all. Maybe you want to fail because you don’t really want to change but just want to be able to say that you tried. Maybe you are trying wholeheartedly but lack strategy. Regardless, relapses are discouraging, confusing, and wear down your morale. You can get stuck in a cycle of self-fulfilling prophecies of failure. What is your relationship with failure?

When I slip I assess the mistake and take steps to improve.

When I slip I sometimes try to stop but keep slipping.

When I slip I get negative or self-loathing

13. Complacency *

How complacent are you with your habits of using porn, illicit sex, or intoxication?

I have a recovery plan or program which I am committed to.

I am in a cycle of resisting and indulging.

I freely indulge any time.

14. Hopelessness *

If you’ve been rowing your recovery boat, without knowing that the anchor of your underlying issues is keeping you stuck, you will feel hopeless. Maybe you haven’t thought about how your behaviors are a cause rather than an effect. Or maybe hopelessness is an excuse to indulge as much you want. It is a sinking feeling inside that will not go away. Any thought of action just seems like useless labor. How are you with hopelessness?

I feel hope to gradually purify myself.

I waver in my morale about purification.

I feel like I’ve tried and always failed, so I might as well give up.

15. Shame *

When you believe there is something inherently wrong with you, having an addiction fits. Of course, you don’t want anyone to see the ‘real you’ because they would not accept you. These are shameful beliefs, how can you relate to this kind of shame?

I feel that my problems are different from who I am as a person and am willing to be open so I can work on them.

I identify with my problems and am uncomfortable being open even if it means I can work on them.

If anyone knew how I really am they would reject me.

16. Secrecy *

From fear and shame comes secrecy. If you get nervous when people use your phone, even though you are pretty sure that you erased your browsing history… you have a problem. You cannot change until you are honest with yourself and trusted people. How are you with secrecy?

I do not keep secrets unnecessarily but seek the right people to open up with.

I am somewhat honest about my life, problems, and feelings. But I sometimes unnecessarily keep things to myself to save face.

No one knows about my sexual addiction.

17. Deception *

In order to maintain the secret, you have tell half-truths, lies, or lies by omission… you have to create misleading impressions… You may do it directly to someone’s face, or simply cover up your tracks to avoid getting caught. You may even delude yourself into thinking you’re okay lying and cheating. How much energy do you put into deceiving others?

I use my intelligence towards my own well-being and do not deceive myself or others.

I impulsively deceive myself or others when I feel like I have something to hide.

I have strong habits of lying, stealing, and deception.

18. Isolation *

You can be isolated even when you are around other people if you do not feel understood and connected. You feel like it’s just you and no one really cares or can help you. Being alone leaves you wanting pleasure and connection. So you turn to porn. How isolated are you?

I let like-minded people of quality into my personal life and have a balance of social and alone time.

I have circumstantial or superficial friendships and too much time alone or online.

I do not let others into my personal life and spend most of my time alone or online.

19. Apathy *

Empathy is caring for the feelings of others, but porn is selfishness, isolation, and secrecy. Some of the largest industries in the world are human and drug trafficking, where vulnerable people are persuaded into degrading and dangerous activities. How much do you feel for the people who are suffering?

I feel for the victims of trafficking who are used and abused.

I see people who let me indulge as objects or means, more than people.

I don’t care if people suffer if I can enjoy.

20. Risk *

When you develop a perverted mentality, everything is sexual. You see what you can get away with, or you figure you won’t get caught. Using porn on your work computer, stealing for intoxication, and having affairs, are risky behaviors. How much do you do things like this?

I do not take risks with sexual activities or intoxication.

I often become triggered at times I deem inappropriate but act on it in later when I choose.

I engage in sexual activities or intoxication in inappropriate times and places at the risk of myself or others.

Denial

I am aware of my personal issues and am working on them.

I sometimes suffer because of my issues but tend to be distracted from uprooting the root causes.

I don’t think my indulgences are really a problem or I don't want to think about it.