Assess

I use porn/masturbation to avoid or escape my feelings and problems or to alter my mood?(Required)

I become restless, moody or irritable when attempting to cut down or stop viewing porn(Required)

I find myself preoccupied with sexual thoughts more often than I would like(Required)

It sometimes seem as if there is a force inside me that drives me to view pornography(Required)

I feel empty or shameful after viewing pornography or masturbating and wish I could stop(Required)

I have promised myself (at least few times in the past) that I would never again view pornography or masturbate(Required)

I have lied to my family members, spiritual leaders or others about my pornography viewing(Required)

My use of pornography interfere with, limit or reduce the social, occupational, educational or recreational areas of my life(Required)

I have stayed up late at night or woke up during the night to view pornography(Required)

I erase history, “cover tracks” and take steps to hide my porn use to avoid being caught(Required)

I rationalize, justify, minimize or make excuses about my pornography use(Required)

I somehow end up looking at pornography nearly every time I get on the internet(Required)

I have participated in on-line/internet sexual chats, emails, posts or in sexting(Required)

I have lied, stolen, manipulated others or made other unwise choices to view pornography(Required)

I worry something is wrong with me because of my sexual thoughts and feelings(Required)

I find myself viewing more and more porn, or different types of porn to feel the desired excitement(Required)

I view more pornography and for longer periods of time than I initially intend(Required)

My sexual thoughts/feelings interfere with my moral/religious beliefs or my family values(Required)

My sexual thoughts and behaviors cause me to feel that I am unclean or unworthy(Required)

I browse through newspapers, magazines or flip though channels on the television just to find something that will stimulate me sexually(Required)

I look for opportunities to be alone so that you can find pornography or masturbate(Required)

I masturbate while viewing pornography(Required)

I continue to view porn despite knowing it may jeopardize or damage my relationships(Required)

I have experienced repeated unsuccessful efforts to control, cut back or stop viewing porn(Required)

I continue to view pornography even after encountering problems related to my viewing(Required)

Your Real Name or Alias(Required)

This is just to use as a reference (not to identify you) when you chat with our counsellors. Feel free to use a fictitious name 🙂

Phone

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