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Pornography Assessment

Any website visitor can take this survey, results of which are confidential. You are not required to leave your name nor will you be contacted by anyone. You will not be placed on a mailing list as a result of taking the survey. The results will be used by medical or psychological practitioners to compile data that can be used in treating those who struggle with addiction to Internet pornography.

Responses will be sent to Sharon Borntrager, director of the National Coalition’s Counseling and Support Department.  She can be reached at Sharon@nationalcoalition.org.

Evaluative Assessment:

Pornography, specifically Internet pornography, can be severely effectual psychologically and, to an extent, physiologically. This can lead to significant pathologies of the human brain. 

Note: This survey is not for the purpose of diagnosis, treatment, or cure of any disease or problem

Gender:
Education:
Male
High School Graduate
Female
Some College


Bachelors Degree
Age:
Masters Degree

Ph.D.
 

Marital Status:
Ages of Children in Home:
Single
Married

Divorced

Separated

Widowed

Please answer the survey below to the best of your ability:

1.  Has pornography impacted your life?

      Strongly
      Somewhat
      Rarely
      Not at all

2.  What were the first signs of this impact? (Short answer please)

      

3.  Do you consider pornography to be an addiction?

      Strongly agree
      Somewhat agree
      Somewhat disagree
      Strongly disagree

4.  Have you sought help for this?

      Yes
      No

5.  Do you currently receive treatment/therapy?

      Yes
      No

6.  Has this affected your family/ social/ spiritual life?

      Strongly agree
      Somewhat agree
      Somewhat disagree
      Strongly disagree

7.  Who introduced you to pornography? (Short answer please)

     

8.  How do you access it? (Short answer please)

     

9.  If you use the Internet to access it, is this access facilitated by Internet websites?

      Yes
      Sometimes
      Rarely
      Never

10.  Please choose 1-3 specific emotions you are feeling when you access porn websites.

      Lonely
      Energetic
      Sad
      Mad
      Scared
      Powerful
      Peaceful
      Other

11.  Do you make efforts to avoid access to these sites?

      Yes
      Sometimes
      Rarely
      Never

12.  If so, are you successful?

      Yes
      Sometimes
      Rarely
      Never

13.  How often do you access the pornography?

      Once a day
      Several times a day
      Once a week
      Several times a week
      Once a month
      Several times a month
      Every few months

14.  Does masturbation accompany your viewing the pornography?

      Yes
      Sometimes
      Rarely
      No

15.  Have you ever asked /requested to stop receiving emails about pornography?

      Yes
      Sometimes
      Rarely
      Never

16.  Do you get Internet pop-ups about pornography or others that lead you to pornography on the Internet?

      Yes
      Sometimes
      Rarely
      Never

17.  Do children also have access to your computer?

      Yes
      No
      Sometimes

18.  Do you think the children have been exposed to any pornographic advertising or websites?

      Yes
      Sometimes
      Rarely
      Never

19.  Do Internet companies give reasonable warnings about the possible addictive nature of their product?

      Yes
      No
      Have not seen any

20.  Has anything positive come from pornography in your life?

      Yes
      No
     If Yes, describe:

     

21.  Have you suffered any financial losses or caused any financial losses for others as a result of Internet pornography?

      Yes
      Significant loss
      Minimum loss
      None

22.  Have you committed any crimes as a result of Internet pornography?

      Yes
      No

23.  Have you been convicted of any crimes as a result of Internet Pornography?

      Yes
      No

If you would not mind being contacted by phone or email, please provide your contact information. The National Coalition maintains the utmost level of privacy. All personal information shared will remain confidential.

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Address:
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