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Kick Start Recovery Programme - Users Background
23.
General Information
2300%
*
1.
Age?
(Required.)
Under 16
16-18
18-25
26-35
36-45
46-55
Over 55
*
2.
Gender
(Required.)
Male
Female
*
3.
Sexual Orientation?
(Required.)
Heterosexual
Gay
Lesbian
Bi
Unknown
*
4.
Where do you currently live?
(Required.)
North East
North West
Midlands
East
London & Home Counties
South East
South West
Wales
Scotland
Northern Ireland
Eire
Europe
USA
Other (please specify)
*
5.
At what age do you think your problem started?
(Required.)
0-10
11-16
17-25
26-35
36-45
46-55
Over 55
Don't know
*
6.
Which of the following statements are true for you?
(Required.)
I was physically or sexually abused as a child
I have experienced traumatic events
I felt neglected as a child
My family background was stable and supportive
I suffer with depression and/or anxiety
My work is very stressful
I didn't know sex/pornography could become addictive until it was too late
*
7.
Please rate your current self esteem based on a 1 to 5 scale where 1 is very low and 5 is very high
(Required.)
Very Low
Low
Average
Good
Very Good
My current self esteem is:
Very Low
Low
Average
Good
Very Good
*
8.
Please indicate which of the following professionals you have approached for help with your problem
(Required.)
GP
GUM Clinic
Psychiatrist
Independent Counsellor/Psychotherapist/Sex Therapist
Relate Counsellor or Sex Therapist
Specialist Sex Addiction Therapist
Online Treatment Provider
Residential Rehabilitation
12 Step Group
Pastor/Minister/Vicar
None
*
9.
Which of the following behaviours do you, or did you, engage in as part of your sexual addiction?
(Required.)
Pornography
Dating Sites/Facebook/hook ups
Telephone sex
Cyber chat
Webcam sex
Adult TV channels
Visiting sex workers
Visiting masseurs
Sex with strangers
Multiple affairs
Exhibitionist/Voyeuristic behaviours (including dogging)
Fetish behaviours
10.
What triggered you to seek help for problem today?