THIS SURVEY IS INTENDED TO BE COMPLETELY ANONYMOUS
Thank you for answering these questions. Please guard against exaggerating and also guard against denying. Answering the questions honestly will help address any hungers or longings of your men’s group, concerning any unmet needs within yours or their hearts. For men who do not struggle with any heart lust or out of control behavior, it is vitally important that you too answer each question so that an accurate pulse can be taken of your men’s group.
For married men, or young men living with others, if your wife, parents or roommates see this survey it could stir curiosity concerning your response. This is not our intent. Therefore we strongly advise this survey be filled out and returned to your facilitator as soon as possible.
Some questions may not apply to you, so circle NA. (Not applicable)
- Are you in agreement with the bible that lust and all sex outside of marriage is sin? Yes No
- What was the primary source of your sex education?
(A) Parents (B) Church (C) School (D) Self-taught (E) Peers (F) Media (G) Other
- Are you currently sexually active with someone other than your spouse? (within this past year?) Yes No
- If so, do you practice safe sex (condoms)? Yes No
- Have you ever fathered a child outside of marriage? Yes No
- Have you ever fathered a child that was aborted? Yes No
- If yes to question 6, did you give consent? NA Yes No
- Did you ever have or do you now have a sexually transmitted disease (STD) or an
sexually transmitted infection (STI?) Yes No
- Have you ever been with a prostitute? Yes No
- In the last three months have you gone on the Internet to adult sites or sex based chat rooms? Yes No
(A) In the past month? (B) In the past week?
- Have you ever used your cell phone for “sexting?” or to view porn?
- In the last three months, have you visited adult bookstores or strip clubs, anyplace
where sexual activity is promoted? Yes No
- Since becoming a Christian, have you ever paid for sex, bought porn, or viewed porn on a computer? Yes No
- At this present time do you own any porn (videos- magazines-books-CD’s–or have any porn stored
on your computer)? Yes No
- Do you currently have a “filter” or “accountability program” installed on your computer
preventing you from viewing porn? Yes No
- If, Yes, does it:
Effectively stop you from looking at porn? _______
Slow you down in your efforts to view porn? _______
Cause you to find new ways to view porn? _______
Challenge you to find ways around it? _______
- In the past four weeks what would you say is the closest number of times you have masturbated?
(A) Once in the past month (B) Once every other week (C) Once a week
(D) Twice a week (E) Three times a week (F) Four times a week
(G) Five times a week (H) Six times a week (I) Daily
(J) Multiple times a day (K) NA ________
- Is lust an on going issue in your life? (A) Never (B) Seldom (C) Often (D) Intense _______
- Concerning any struggle with the issue of sexuality in your life (lust or behavior) do you struggle
with shame (various degrees of self-hatred)?
(A) Never (B) Seldom (C) Often (D) Intense (E) NA _ _____
- Concerning any struggle with sexual issues (lust or behavior), do you experience guilt?
(A) Never (B) Seldom (C) Often (D) Intense (E) NA ___ ___
- Does lust or any out of control sexual behavior seem to hit you in cycles? (Bingeing)
If so, How Often? # __________Weekly # ______ monthly # ______ a year?
Or is it something that cannot be measured by “time” but more accurately by your “mood swings?”
e.g. feeling lonely, feeling angry, feeling rejected? (A) Never (B) Seldom (C) Often (D) NA _______
- If married and you struggle sexually, is your wife aware of your struggle?
(A) Aware (B) Somewhat Aware (C) Unaware (D) NA ________
- Do you consider yourself a sex addict? Yes No
- Are you currently in an accountability relationship concerning this topic with another man or men? Yes No
- If all your thought’s and secrets were known, including your sexual ones, do you think the pastors
and elders of this church would reject you? Yes No
- Do you think the pastor and elders at this church would be a help, a source of further shame/rejection
or are unequipped to help you if you shared your sexual struggles with them?
(A) Help (B) Source of Shame/Rejection (C) Unequipped _______
- Are you willing to be transparent and entrust the men within this group with your sexual issues? Yes No
- Circle five of the following words that are the most prominent issues in your life.
Anger Rage Hatred Bitterness Pride Unbelief Substance Abuse Addictions of any Kind Jealousy Judging Others
Marriage Loneliness Unforgiveness Rejection Guilt Self-hatred Self-pity Gossip Lying Stealing Prayerlessness
Shame Beng Deceitful Laziness Prejudice Workaholism DepressionPerformance Orientation Perfectionism
Other – -______________________________ ________________________________
- Have you been totally honest in answering this survey? Yes No