1. Were you sexually abused as a child or adolescent? 1. Were you sexually abused as a child or adolescent? Yes No

2. Did your parents have trouble with sexual behavior? 2. Did your parents have trouble with sexual behavior? Yes No

3. Do you often find yourself preoccupied with sexual thoughts? 3. Do you often find yourself preoccupied with sexual thoughts? Yes No

4 .Do you feel that your sexual behavior is not normal? 4 .Do you feel that your sexual behavior is not normal? Yes No

5 . Do you ever feel bad about your sexual behavior? 5 . Do you ever feel bad about your sexual behavior? Yes No

6. Has your sexual behavior ever created problems for you and your family? 6. Has your sexual behavior ever created problems for you and your family? Yes No

7. Have you ever sought help for sexual behavior you did not like? 7. Have you ever sought help for sexual behavior you did not like? Yes No

8. Has anyone been hurt emotionally because of your sexual behavior? 8. Has anyone been hurt emotionally because of your sexual behavior? Yes No

9. Are any of your sexual activities against the law? 9. Are any of your sexual activities against the law? Yes No

10. Have you made efforts to quit a type of sexual activity and failed? 10. Have you made efforts to quit a type of sexual activity and failed? Yes No

11. Do you hide some of your sexual behaviors from others? 11. Do you hide some of your sexual behaviors from others? Yes No

12. Have you attempted to stop some parts of your sexual activity? 12. Have you attempted to stop some parts of your sexual activity? Yes No

13. Have you felt degraded by your sexual behaviors? 13. Have you felt degraded by your sexual behaviors? Yes No

14. When you have sex, do you feel depressed afterwards? 14. When you have sex, do you feel depressed afterwards? Yes No

15. Do you feel controlled by your sexual desire? 15. Do you feel controlled by your sexual desire? Yes No

16. Have important parts of your life (such as job, family, friends, leisure activities) been neglected because you were spending too much time on sex? 16. Have important parts of your life (such as job, family, friends, leisure activities) been neglected because you were spending too much time on sex? Yes No

17. Do you ever think your sexual desire is stronger than you are? 17. Do you ever think your sexual desire is stronger than you are? Yes No

18. Is sex almost all you think about? 18. Is sex almost all you think about? Yes No

19. Has sex (or romantic fantasies) been a way for you to escape your problems? 19. Has sex (or romantic fantasies) been a way for you to escape your problems? Yes No

20. Has sex become the most important thing in your life? 20. Has sex become the most important thing in your life? Yes No

Can we contact you to schedule a counseling session? Can we contact you to schedule a counseling session? Yes please No thanks

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