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Life Changing Services Self-Mastery Assessment
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1
Are you completing this assessment for yourself or someone you care about?
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Myself
Someone I care about
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2
4. How old is the individual?
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Under 18
18 - 25
25 - 45
45 or more
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3
5. Gender of Individual you are answering for?
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Male
Female
Male
Female
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4
How often does the individual feel tempted to view, read about or do sexual things outside of their value system?
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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
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5
Temptation Question Weighted Score
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6
How often does the individual actually view or read about sexually things outside of their value system?
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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
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7
Read or View Score
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8
How often does the individual participate in sexually inappropriate acts like masturbation?
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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
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9
Sexual Acts Score
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10
If exposure to sexually inappropriate material has occurred, does the frequency to exposure appear to be increasing or decreasing?
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Increasing
Decreasing
It seems to be about the same frequency
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11
Exposure Increase Score
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12
Does the individual quickly admit to any exposure to inappropriate material if confronted, or voluntarily reports exposures
*
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YES
NO
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13
Admit to Exposure Score
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14
Does the individual hide their activity with sexual inappropriate material or actions unless confronted?
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YES
NO
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15
Hide Activity Score
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16
How often do you notice the individual underperforming or apathetic in academics, social situations, extracurricular activities, employment, etc?
*
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Daily
Several days per week
A few times per month
Rarely ever
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17
Underperforming Score
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18
How often do you notice the individual experiencing unusual moods including depression or anger
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Multiple times per day
At least once daily
Several days per week
A few times per month
Rarely ever
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19
Mood Score
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20
Does the frequency of unusual behavior seem to be increasing or decreasing
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Increasing
Decreasing
The frequency appears to be the same
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21
Mood Increase Score
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22
Do you notice the individual often misrepresenting the truth?
*
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YES
NO
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23
Lie Score
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24
Does the individual frequently express disrespect for authority figures in his/her life.
*
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YES
NO
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25
Disrespect Score
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26
Does the individual frequently show significant apathy towards activities that were once interesting to them?
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YES
NO
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27
Apathy Score
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28
Does the individual demonstrate a significantly lack or reduction in his/her self-confidence?
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YES
NO
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29
Self Confidence Score
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30
Do you notice the individual making promises or commitments and frequently unable to keep them?
*
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YES
NO
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31
Promises Score
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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.
*
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YES
NO
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33
Controls Score
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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
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35
Final Assessment Score
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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?
YES
NO
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37
Your First Name
*
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38
Your Email
*
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example@example.com
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39
Best Contact Phone Number
Area Code
Phone Number
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