Self-Mastery Assessment

1

Are you completing this assessment for yourself or someone you care about?* This field is required.

Myself

Someone I care about

2

4. How old is the individual?* This field is required.

Under 18

18 - 25

25 - 45

45 or more

3

5. Gender of Individual you are answering for?* This field is required.

4

How often does the individual feel tempted to view, read about or do sexual things outside of their value system?* This field is required.

Multiple Times a Day

At least once per day

A few times per week

Once per week

Less than once every other week

About once per month

Once every 3 months or less

I don't know

5

Temptation Question Weighted Score

6

How often does the individual actually view or read about sexually things outside of their value system?* This field is required.

Multiple Times a Day

A few times a day

At least once per day

A few times per week

Once per week

Less than once every other week

About once per month

Once every 3 months or less

I don't know

7

Read or View Score

8

How often does the individual participate in sexually inappropriate acts like masturbation?* This field is required.

Multiple Times a Day

A few times a day

At least once per day

A few times per week

Once per week

A few times per month

About once per month

Once every 3 months or less

I don't know

9

Sexual Acts Score

10

If exposure to sexually inappropriate material has occurred, does the frequency to exposure appear to be increasing or decreasing?* This field is required.

Increasing

Decreasing

It seems to be about the same frequency

11

Exposure Increase Score

12

Does the individual quickly admit to any exposure to inappropriate material if confronted, or voluntarily reports exposures* This field is required.

YESNO

13

Admit to Exposure Score

14

Does the individual hide their activity with sexual inappropriate material or actions unless confronted?* This field is required.

YESNO

15

Hide Activity Score

16

How often do you notice the individual underperforming or apathetic in academics, social situations, extracurricular activities, employment, etc?* This field is required.

Daily

Several days per week

A few times per month

Rarely ever

17

Underperforming Score

18

How often do you notice the individual experiencing unusual moods including depression or anger* This field is required.

Multiple times per day

At least once daily

Several days per week

A few times per month

Rarely ever

19

Mood Score

20

Does the frequency of unusual behavior seem to be increasing or decreasing* This field is required.

Increasing

Decreasing

The frequency appears to be the same

21

Mood Increase Score

22

Do you notice the individual often misrepresenting the truth?* This field is required.

YESNO

23

Lie Score

24

Does the individual frequently express disrespect for authority figures in his/her life.* This field is required.

YESNO

25

Disrespect Score

26

Does the individual frequently show significant apathy towards activities that were once interesting to them?* This field is required.

YESNO

27

Apathy Score

28

Does the individual demonstrate a significantly lack or reduction in his/her self-confidence?* This field is required.

YESNO

29

Self Confidence Score

30

Do you notice the individual making promises or commitments and frequently unable to keep them?* This field is required.

YESNO

31

Promises Score

32

Does the individual react with negativity to blocks being put on electronic devices and rules regarding use of and/or possession of media devices.* This field is required.

YESNO

33

Controls Score

34

Has the individual suffered from some level of addiction with pornography at one time but now demonstrates the ability to avoid pornography and inappropriate behaviors for long periods of time (less than 3 months) or possibly permanently?

YES

NO

Does Not Apply to this Individual

35

Final Assessment Score

36

Would you like to talk right away with a trained representative from Life Changing Services about any concerns you have for yourself or a loved one?

YESNO

37

Your First Name* This field is required.

38

Your Email* This field is required.

example@example.com

39

Best Contact Phone Number

Area Code

Phone Number