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General Information

Age?

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* 1. Age?

Gender

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* 2. Gender

Sexual Orientation?

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* 3. Sexual Orientation?

Where do you currently live?

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* 4. Where do you currently live?

At what age do you think your problem started?

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* 5. At what age do you think your problem started?

Which of the following statements are true for you?

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* 6. Which of the following statements are true for you?

Please rate your current self esteem based on a 1 to 5 scale where 1 is very low and 5 is very high

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* 7. Please rate your current self esteem based on a 1 to 5 scale where 1 is very low and 5 is very high

  Very Low Low Average Good Very Good
My current self esteem is:
Please indicate which of the following professionals you have approached for help with your problem

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* 8. Please indicate which of the following professionals you have approached for help with your problem

Which of the following behaviours do you, or did you, engage in as part of your sexual addiction?

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* 9. Which of the following behaviours do you, or did you, engage in as part of your sexual addiction?

What triggered you to seek help for problem today?

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* 10. What triggered you to seek help for problem today?

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