Name *

First Name

Last Name

Question 1 *

How long have you been struggling with this problem?

Less than 1 year

2 years

More than 2 years

Question 2 *

Have you tried to stop or limit your sexual behaviour?

Yes but unable to stop

Never tried

Been able to limit it but not able to stop

I could stop if I tried

Question 3 *

Does your sexual behaviour contradict your personal values and potentially limit your goals in life?

Yes

No

Question 4 *

Does your sexual behaviour have a negative impact on other areas of your life such as relationships, work, finances, health, professional status?

Yes

No

Question 5 *

Have you noticed that you need more and more stimuli or risk in order to achieve the same level of arousal and excitement?

Yes

No

Question 6 *

Are you more tempted to engage in sexual behaviour when you're experiencing difficult feelings such as stress, anxiety, anger, depression or sadness?

Yes

No

Question 7

Are you secretive about sexual behaviour and fearful of being discovred?

Yes

No

Question 8 *

Do you feel dependent on your sexual behaviour and struggle to feel fulfilled with any alternative?

Yes

No

Question 9 *

Have you noticed you are struggling to concentrate on other areas of your life because of your thoughts and feelings about your sexual behaviour?

Yes

No

Question 10 *

Do you feel your sexual behaviour is out of control?

Yes

No