Program Assessment Questionaire

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What type of support can best help my situation?

Complete this questionaire as honestly as possible, and we'll send you recommendations on how to best support your circumstance

29Questions

1
A “Values System” is your personal rule book for what is right and what is wrong. This survey helps you to evaluate the degree to which you are acting against your Values System and what level of support you may need to help you be more successful in your choices.

Before filling out the following questionnaire, please make a list of the top 5 ways that you act against your Values System. This could be anything from overeating to looking at pornography.
2
Are you completing this questionnaire for yourself or for someone you care about?
Myself
Someone I care about
3
Are you a wife of someone who is struggling with possible addictions like pornography addiction?
YESNO
4
If you are seeking for help with the effects of betrayal trauma from your marriage, we recommend that you consider the WORTH program for those who are working to save their marriage or WORTH Divorce for those who have decided that divorce is their best option. You can visit www.LifeChangingServices.org/Worth to learn more about the program.

If you would still like to explore other issues you may need help with, click 'Next' to complete the remainder of the Assessment.
5
Since you have indicated that you are completing this for someone you care about, please answer the following questions for them as accurately as possible.
6
This assessment is written in third person. Since you have indicated that you are completing this for yourself, please answer the following questions for yourself as accurately as possible.
7
Does the individual have any recurring behaviors that contradict their values system?
YESNO
8
Based on your answer, we are unable to help this individual with any of Life Changing Services' Programs. The first step to getting support is to recognize that you are acting against your value system. Would you like to try answering the previous question differently?
YES
NO
9
Does it bother the individual that they are acting against their values?
YESNO
10
Based on your answer, we are unable to help you with any of Life Changing Services' Programs. An important step to getting support is to feel some level of regret for your actions. Would you like to try answering the previous question differently?
YES
NO
11
Individual's Gender
Male
Female
12
Individual's age range
Under 18 years old
18 to 23 years old
Older than 23 year old
13
Individual's marital status
Single
Married
14
Are the individual's actions against their value system primarily of a sexual nature (pornography, masturbation, sexual interactions outside their values system)?
YESNO
15
Are the individual's actions against their value system primarily of a self-harming nature (cutting, burning, hitting, etc)?
YESNO
16
How often has the individual acted against their Value System?
Less than 1 every 3 months
Between once every 2 weeks and once every 3 months
More often than once every 2 weeks
IN THE PAST more often than once every two weeks but NOW less than once every 3 months
17
Approximately how many times has the individual seriously committed to themselves that they would not act against their value system, but they have lost again and again anyway?
Less than 3 times in the past 8 weeks
Between 3 and 10 times in the past 8 weeks
More than 10 times in the past 8 weeks
18
Are the individual's actions against their value system primarily anger related (raising voice, sarcasm, name calling, mean words)?
YESNO
19
Are the individual's actions against their value system primarily drug related?
YESNO
20
Are the individual's actions against their value system primarily food/exercise/health related?
YESNO
21
Are the side effects of the individual's actions against their value system having a negative impact on their marital relationship?
YESNO
22
To what degree is the individual's most important relationship(s) still damaged due to a history (past or present) of these actions?
Severely
Moderately
Minor
Not sure
23
Would you like more information on how to win your important Battles?
YESNO
24
Would you like a complimentary consultation regarding training or services that LCS offers regarding the types of Battles you (and/or your loved ones) are fighting?
YESNO
25
Your Name
First Name
Last Name
26
Your First Name* This field is required.
27
Your Last Name
28
Your Email* This field is required.
example@example.com
29
Your Phone Number* This field is required.
Area Code
Phone Number
30
Thanks for completing your assessment. Click Submit to receive your customized report from Life Changing Services.
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