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* 1. Has your sexual behavior ever created problems for you?

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* 2. Has your sexual behavior ever created problems for others?

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* 3. Do you ever hide any of your sexual behavior from others?

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* 4. Do you feel controlled by your sexual desire?

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* 5. I use sexual behavior or fantasy to escape.

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* 6. I was first exposed to pornography at age _____. 

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* 7. I have sought out pornography in the last _____.  (Mark all that apply)

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* 8. When you have sex or act out sexually, do you feel sad afterwords?

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* 9. When I am struggling with sexual behavior I do not like, I have pursued a friend or peer for help.

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* 10. I believe my unwanted sexual behavior is the primary hinderance in my spiritual journey.

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* 11. If you would like some tools to help you achieve real freedom, please list your email and/or phone number.

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* 12. If you listed your email and/or phone number above, please check the type of resources you would like to receive. 


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