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)


  1. Are you in agreement with the bible that lust and all sex outside of marriage is sin?                                       Yes    No         


  1. What was the primary source of your sex education?

         (A) Parents    (B) Church      (C) School     (D) Self-taught   (E) Peers   (F) Media  (G) Other                                                                                                                


  1. Are you currently sexually active with someone other than your spouse?   (within this past year?)               Yes   No


  1. If so, do you practice safe sex (condoms)?                                                                                                     Yes   No


  1. Have you ever fathered a child outside of marriage?                                                                                 Yes   No


  1. Have you ever fathered a child that was aborted?                                                                                    Yes    No


  1. If yes to question 6, did you give consent?                                                                                             NA   Yes    No           


  1. Did you ever have or do you now have a sexually transmitted disease (STD) or an                                         

          sexually transmitted infection (STI?)                                                                                                        Yes   No


  1. Have you ever been with a prostitute?                                                                                                           Yes    No


  1. 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?                                                                                                        


  1. Have you ever used your cell phone for “sexting?” or to view porn?                                                                     

                                                                                                                                                                               Yes    No

  1. In the last three months, have you visited adult bookstores or strip clubs, anyplace  

        where sexual activity is promoted?                                                                                                                   Yes     No


  1. Since becoming a Christian, have you ever paid for sex, bought porn, or viewed porn on a computer?       Yes    No


  1. At this present time do you own any porn (videos- magazines-books-CD’s–or have any porn stored

       on your computer)?                                                                                                                                             Yes   No


  1. Do you currently have a “filter” or “accountability program” installed on your computer

       preventing you from viewing porn?                                                                                                                    Yes    No


  1. 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?                                                                                         _______

                              NA                                                                                                                                                  _______






  1. 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                                                                                                    ________



  1. Is lust an on going issue in your life? (A) Never      (B) Seldom      (C) Often      (D) Intense                      _______  


  1. 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                                                                                    _  _____


  1. Concerning any struggle with sexual issues (lust or behavior), do you experience guilt?

           (A) Never  (B) Seldom      (C) Often      (D) Intense      (E) NA                                                                         ___ ___


  1. 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                 _______


  1. If married and you struggle sexually, is your wife aware of your struggle?

           (A) Aware  (B) Somewhat Aware      (C) Unaware      (D) NA                                                                       ________


  1. Do you consider yourself a sex addict?                                                                                                    Yes      No


  1. Are you currently in an accountability relationship concerning this topic with another man or men?           Yes      No


  1. 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


  1.   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                                                                            _______   


  1. Are you willing to be transparent and entrust the men within this group with your sexual issues?                   Yes     No


  1. 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   

      Generational Sins    


Other – -______________________________    ________________________________        



  1. Have you been totally honest in answering this survey?                                                                                  Yes    No



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