Full Name: Email Address:

1. Are you or your loved one preoccupied by sex?

yesno

2. Have your/their desires driven you/them to have sex in places or with people you/they normally would not choose?

yesno

3. Do you or your loved one purchase sexually explicit material in print or online?

yesno

4. Does the use of pornography occupy large amounts of time jeopardizing significant relationships or employment?

yesno

5. Could your/their sexual practices cause legal problems?

yesno

6. Do you feel you or your loved ones sexual behavior is abnormal?

yesno

7. Do you/they compulsively avoid sexual activity due to fear of sex or intimacy? Are you/they highly avoidant to sex in intimate relationship?

yesno

8. Are you or your loved one is leading a double life?

yesno

9. Does your/their spouse/partner complain about your/their sexual behavior?

yesno

10. Has your/their sexual behavior interfered with your/their family life? Or if they do not know, if they did would it interfere?

yesno

11. Have you or your loved one been unable to stop your/their sexual behavior even though you know it is inappropriate?

yesno

If you answered yes to 3 or more it is an indication your loved one needs help. Call Alchemy Consulting and we can help you find the right resources for your family.