Welcome Questionnaire for Men
As we begin, let me know a little about where you are and where this all started. Please answer each question fully and to the best of your ability. Even if you don't think it is relevant, please give more information, rather than less.
All responses are confidential.
Your age now
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Occupation{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Education
GEDHigh schoolTechnical schoolAssociate degreeBachelor degreeGraduate school{"type":"select","name":"__generic3","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"GED\nHigh school\nTechnical school\nAssociate degree\nBachelor degree\nGraduate school"}
Living Situation
Live aloneLive with parentsLive with spouseLive with spouse and child(ren)Live with girlfriend/fianceeLive with roommate(s)other{"type":"select","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Live alone\nLive with parents\nLive with spouse\nLive with spouse and child(ren)\nLive with girlfriend/fiancee\nLive with roommate(s)\nother"}
Use of Alcohol- pick as many as are true.
{"type":"checkbox","name":"__generic5","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never used \nCurrently do not use alcohol\nSocial use of alcohol\nPast heavy use of alcohol\nUse now only in moderation\nUse alcohol to excess at times\nDaily overuse of alcohol"}
Use of Drugs
Never used and do not use drugsPast history of drug use, none nowUse drugs at times{"type":"select","name":"__generic6","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never used and do not use drugs\nPast history of drug use, none now\nUse drugs at times"}
Mental Health History
click any that you have been diagnosed with:
{"type":"radio","name":"__generic7","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Depression\nAnxiety\nBipolar\nPTSD\nPersonality Disorder\nAutism spectrum\nSchizophrenia\nADD/ADHD"}
Addictions
list any addictions you have or think you may have
{"type":"checkbox","name":"__generic8","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Alcohol\nTobacco\nOpioids\nPrescription drugs\nCocaine\nMarijuana\nAmphetamines\nHallucinogens\nInhalants\nPCP\nFood Addiction\nSex Addiction\nLove addiction\nInternet Addiction\nPornography Addiction\nUsing computers and/or cell phones\nVideo Game Addiction\nWork Addiction\nExercise Addiction\nSpiritual obsession (not to be confused with religious devotion)\nSeeking pain\nCutting\nShopping Addiction\nExercise\nGambling Addiction\nother"}
Religious Upbringing
{"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"childhood religious experience, if any. "}
Current Faith
{"type":"textarea","name":"__generic10","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"What is your current relationship with and understanding of God?"}
Where Things went South...
When you began pursuing unwanted sexual behavior:
How old were you?
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My unwanted sexual behavior(s):
{"type":"checkbox","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Pornography\nMasturbation\nAffair/adultery\nHookups\nChat rooms\nProstitutes\nSexting\nSame-sex attraction\nWebcams\nErotic massage parlors\nStrip clubs\nother"}
My Favorite Porn Searches:type in exactly what you would most often enter in a search box or chat
{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"when looking at internet porn... what are the top 5 search terms you will seek"}
{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"when looking at internet porn... what are the top 5 search terms you will seek"}
{"type":"text","name":"__generic15","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"when looking at internet porn... what are the top 5 search terms you will seek"}
{"type":"text","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"when looking at internet porn... what are the top 5 search terms you will seek"}
{"type":"text","name":"__generic17","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"when looking at internet porn... what are the top 5 search terms you will seek"}
How different is your own masculinity to what you think is “normal” or expected?
Very SameSomewhat SameSomewhat DifferentVery Different{"type":"select","name":"__generic18","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Very Same\nSomewhat Same\nSomewhat Different\nVery Different"}
Marital Status
MarriedMarried, but separatedSingle, never marriedSingle, divorcedSingle, widowed{"type":"select","name":"__generic19","width":45,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Married\nMarried, but separated\nSingle, never married\nSingle, divorced\nSingle, widowed"}
Describe your Partner- things your wife/ex/girlfriend has done or is doing that bother you.
{"type":"checkbox","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Low sex drive\nHigh sex drive\nAffair/cheated on you\nNo orgasm during sex\nUnrealistic expectations\nPornography\nMasturbation\nChat rooms\nSame-sex attraction\nother"}
Marriage
{"type":"textarea","name":"__generic21","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Describe your current marriage situation. If unmarried, describe your \"ideal\" marriage"}
Anything else...you want me to know as we begin?
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How would you define a "sexually healthy man" ?
{"type":"textarea","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
If together you and I can change one thing in your life by this work together, what would it be?
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Prior to beginning our work together, what other resources have you tried or are still using to gain traction or healing for your unwanted sexual behaviors?
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If you checked off yes to any of the professional resources above (pastor, counselor) please briefly describe your work with them and the outcome
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If you checked off yes to any of the media resources above, (book, podcast, website) please list specific titles{"type":"textarea","name":"__generic27","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
If you checked off yes to any of the group resources above, (recovery group, intensives) please list specific organization and if you are still attending, etc.{"type":"textarea","name":"__generic28","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
The first step to freedom is always
asking for help. What is the most difficult part for you in asking for help?
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Why Me? Why Now?
Your struggles are not new. You have tried to change many times in the past. You've seen some success and slips along the way. What is the reason, to the best you understand it, for reaching out and starting this therapy and mentoring now?{"type":"textarea","name":"__generic29","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
I look forward to unpacking your story and seeing how God will redeem it.
