Sexual Addiction Screening Inventory              

Choose one of the following options:

I think of sexual things from time to time
I think of sexual things throughout the day
I think of sexual things to the point of obsession

Choose one of the following options:

-select one of the options- I have engaged in masturbation appoximately once/twice a month I have engaged in masturbation about once a week I have engaged in masturbation about every other day I have engaged in masturbation about every day

Select any of the following behaviors that apply to you:

masturbation	masturbation w/ pornography	voyeurism (looking at people)	        
internet chatting	internet sex		phone sex		                              
anonymous sex	sex with prostitutes	sexual behavior with animals	
pornography	porn video		porn stores       

exhibitionism 	strip clubs		sexual behavior with minors 

4. Describe the effects of what your sexual behavior is costing you.

   
   

5. Have you ever felt ashamed of your sexual behavior?

   Yes No

   
   

6. Have you tried to control your sexual behavior?

   Yes No

   
   

7. Have you ever felt you spent to much time acting out?

   Yes No

   
   

8. Have you felt that you life was controlled by fantasy?

   Yes No

   
   

9. On a scale of 1 to 5 (1= little motivation, 5=high motivation) where are you in terms of wanting to be free?

   1 2 3 4 5

   
   

10. Briefly describe your marital relationship? (N/A if you aren't married)

    
    

11. Has your spouse (or family member) ever been concerned about your behavior?

    Yes No

    
    

12. Do you resort to sex to escape, relieve anxiety, or because you can't cope?

    Yes No

    
    

13. Do you lose time from work for it?

    Yes No

    
    

14. Have you ever been arrested for your sexual behavior?

    Yes No

    
    

15. When did your troublesome sexual behavior start?

    I would like feedback from Erik Bohlin, M.A., LMHC.  Please include your name,

    phone number and whatever information you would like. 

    This screening devise is not intended to replace a professional assessment or therapy,

    but can get you pointed in the right direction.

    Name, Phone number, email or address