SEXUAL HEALTH ASSESSMENT (Part 2 of the Comprehensive Assessment for Coaching)
This assessment is to gather baseline information from those participating in Professional Coaching. However, if you are not participating in professional coaching, but would like your assessment evaluated, we will do so--as time and energy permit--in the order that it was received. You must supply a password to retrieve the results.
General Information:
Briefly describe your reason for seeking assessment (e.g. Part of Professional Coaching Process, curiosity, advice of counselor, etc.):
Begin Assessment (Part 1 of 12)
1. What is your current sexual preference? Heterosexual Homosexual Bi-sexual Auto-sexual (masturbation) Asexual (abstinence) Other
a. Describe "other":
2. At what age did you become aware of your current sexual preference?
1-96 Enter age of awareness; 0-If always preferred; 97-If Unknown
3. Are you satisfied with your current sexual preference? 1-Yes 2-No 3-Unsure
4. How many sexual/romantic partners have you had:
a. In the past 30 days? b. In the past year? c. In your lifetime?
5. Of the sexual partners you have had, how often have you maintained 'safe-sex' practices?
1-Always 2-Usually 3-Seldom 4-Never 5-Not Applicable
6. Are you engaging in sexual behavior that is having (could have) a significantly impact on your life?
1-Yes 2-No 3-Unsure
7. Document your experiences with the following:
For all behaviors exhibited below, click on the corresponding "follow-up" link
Behavior
Age of
1st Experience
(1-96; 0 if never)
Follow-up Questions
8. For the behaviors listed in the chart above, enter the letter (A-T) for each behavior you have exhibited for longer than one year:
9. Have you ever been treated for sexually compulsive behavior? 1-Yes 2-No
If Yes: a) How many times? b) How long ago was the last treatment? c) How long did that treatment last? d) What was the treatment setting? 1-Inpatient 2-Outpatient (monitored) 3-Outpatient (self-monitored)e) Did you successfully complete the program? 1-Yes 2-No 3-Unsure/Not Applicable
If Yes:
a) How many times? b) How long ago was the last treatment? c) How long did that treatment last? d) What was the treatment setting? 1-Inpatient 2-Outpatient (monitored) 3-Outpatient (self-monitored)e) Did you successfully complete the program? 1-Yes 2-No 3-Unsure/Not Applicable
10. Has a friend, employer, family member, etc. ever suggested counseling to help you deal with a matter directly or indirectly related to your sexual/romantic behavior? 1-Yes 2-No
11. Using the scale below, rate the negative impact that your sexual and/or romantic behaviors have had on your: (1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)
*Follow-up Questions (to be answered if behavior listed above)
A) Masturbation
1. On average, how many times per day do you masturbate? 2. How often do you masturbate in public places? Never Seldom Often 3. How often do you masturbate while driving (or other dangerous environments)? Never Seldom Often 4. How often do you masturbate at work? Never Seldom Often 5. Do you believe that masturbating is interfering with your ability to manage intimate relationships with others? Yes No Possibly 6. How many times have you attempted Autoerotic Asphyxiation? 7. How often do you masturbate to the point of exhaustion? Never Seldom Often 8. How often do you feel guilty after masturbating? Never Seldom Often Return
1. On average, how many times per day do you masturbate? 2. How often do you masturbate in public places? Never Seldom Often 3. How often do you masturbate while driving (or other dangerous environments)? Never Seldom Often 4. How often do you masturbate at work? Never Seldom Often 5. Do you believe that masturbating is interfering with your ability to manage intimate relationships with others? Yes No Possibly 6. How many times have you attempted Autoerotic Asphyxiation? 7. How often do you masturbate to the point of exhaustion? Never Seldom Often 8. How often do you feel guilty after masturbating? Never Seldom Often
Return
B) Pornography
1. How many times per week do you view pornographic material? 2. Which types of pornography do you solicit? Soft Hard Both Neither 3. Which types of pornography do you solicit? Adult Child Both Neither 4. Which medium do you prefer? Magazines Videos Internet Variety 5. How many memberships (include trial memberships) to sexual sites on the internet have you joined? 6. How much money have you spent on pornography or pornographic subscriptions in: The past month? The past year? 7. Have you ever received child pornographic materials through the mail or on the Internet? 1-Yes 2-No Return
1. How many times per week do you view pornographic material? 2. Which types of pornography do you solicit? Soft Hard Both Neither 3. Which types of pornography do you solicit? Adult Child Both Neither 4. Which medium do you prefer? Magazines Videos Internet Variety 5. How many memberships (include trial memberships) to sexual sites on the internet have you joined? 6. How much money have you spent on pornography or pornographic subscriptions in:
The past month? The past year?
7. Have you ever received child pornographic materials through the mail or on the Internet? 1-Yes 2-No
C) Promiscuity
1. How many sexual partners have you had in the past year? 2. How many sexual partners have you had in your lifetime? 3. How many times have you been diagnosed with an STD? 4. In the past year, how many times have you had sex with more than one person on the same day? 5. How often do you have sex with someone you've known for less than a month? Never Seldom Often 6 How often do you have unprotected sex? Never Seldom Often 7. In the past ten years, how many times have you had a sexual affair with someone other than partner you were committed to? 8. In the past ten years, how many times have you had a sexual affair with someone who was involved in a committed relationship with someone else? Return
1. How many sexual partners have you had in the past year? 2. How many sexual partners have you had in your lifetime? 3. How many times have you been diagnosed with an STD? 4. In the past year, how many times have you had sex with more than one person on the same day? 5. How often do you have sex with someone you've known for less than a month? Never Seldom Often 6 How often do you have unprotected sex? Never Seldom Often 7. In the past ten years, how many times have you had a sexual affair with someone other than partner you were committed to? 8. In the past ten years, how many times have you had a sexual affair with someone who was involved in a committed relationship with someone else?
D) Transvestism
1. How often do you cross-dress in public? Never Seldom Often 2. When in public, which facilities do you use? Biologically similar Biologically opposite Both 3. How many people know about your cross-dressing? Nobody Few people Many people 4. How often does your cross-dressing negatively impact your ability to maintain social relationships? Never Seldom Often Return
1. How often do you cross-dress in public? Never Seldom Often 2. When in public, which facilities do you use? Biologically similar Biologically opposite Both 3. How many people know about your cross-dressing? Nobody Few people Many people 4. How often does your cross-dressing negatively impact your ability to maintain social relationships? Never Seldom Often
E) Fetishism
1. What is the main item(s) of your fetish? 2. How often can you obtain sexual gratification without these items? Never Seldom Often 3. How often do you steal the objects you desire? Never Seldom Often 4. How often has your fetishism negatively impacted intimate relations with your sexual partner? Never Seldom Often Return
1. What is the main item(s) of your fetish? 2. How often can you obtain sexual gratification without these items? Never Seldom Often 3. How often do you steal the objects you desire? Never Seldom Often 4. How often has your fetishism negatively impacted intimate relations with your sexual partner? Never Seldom Often
F) Erotic Fantasy
1. How often do you fantasize while driving, operating machinery, or performing other tasks that requires concentration? Never Seldom Often 2. How often do your fantasies involve coercion or violence? Never Seldom Often 3. How often do your fantasies involve sexual acts with children under the age of 18? Never Seldom Often 4. Rate the negative impact fantasizing has had on your work production: No Effect Slight Moderate Considerable Extreme Return
1. How often do you fantasize while driving, operating machinery, or performing other tasks that requires concentration? Never Seldom Often 2. How often do your fantasies involve coercion or violence? Never Seldom Often 3. How often do your fantasies involve sexual acts with children under the age of 18? Never Seldom Often 4. Rate the negative impact fantasizing has had on your work production: No Effect Slight Moderate Considerable Extreme
G) Prostitution
1. How often do you allow yourself to be prostituted? Never Seldom Often 2. How often do you solicit the services of a prostitute?3. Have you solicited the services of street prostitutes? 1-Yes 2-No4. Have you solicited the services of call girls? 1-Yes 2-No5. What gender do you prefer in your sexual partner? Same Sex Opposite Sex Either 6. How much money have you spent on prostitution services in the last year? 7. How often do you practice safe sex techniques while being serviced by prostitutes? Never Seldom Often Always 8. How many times have you been arrested for a prostitution-related offense? Return
1. How often do you allow yourself to be prostituted? Never Seldom Often 2. How often do you solicit the services of a prostitute?3. Have you solicited the services of street prostitutes? 1-Yes 2-No4. Have you solicited the services of call girls? 1-Yes 2-No5. What gender do you prefer in your sexual partner? Same Sex Opposite Sex Either 6. How much money have you spent on prostitution services in the last year? 7. How often do you practice safe sex techniques while being serviced by prostitutes? Never Seldom Often Always 8. How many times have you been arrested for a prostitution-related offense?
H) Voyeurism
1. How often do you voyeur on private property? Never Seldom Often 2. How often do you enter the dwelling you are voyeuring? Never Seldom Often Always 3. How often do you take souvenirs from a place you have voyeured? Never Seldom Often Always 4. How often do you masturbate while you are voyeuring? Never Seldom Often Always 5. How often do you voyeur in public restrooms/ locker rooms or showers? Never Seldom Often 6. What mechanical devices (e.g. binoculars, night-vision goggles) have you used to assist you? 7. How many times have you been arrested for a voyeur-related offense? Return
1. How often do you voyeur on private property? Never Seldom Often 2. How often do you enter the dwelling you are voyeuring? Never Seldom Often Always 3. How often do you take souvenirs from a place you have voyeured? Never Seldom Often Always 4. How often do you masturbate while you are voyeuring? Never Seldom Often Always 5. How often do you voyeur in public restrooms/ locker rooms or showers? Never Seldom Often 6. What mechanical devices (e.g. binoculars, night-vision goggles) have you used to assist you? 7. How many times have you been arrested for a voyeur-related offense?
I) Exhibitionism
1. In what manner do you expose yourself? Passively Aggressively Both 2. How often do you expose yourself to children? Never Seldom Often Always 3. How often do you expose yourself in public? Never Seldom Often Always 4. How often do you expose yourself in private? Never Seldom Often Always 5. How often does your exhibitionism include others watching you masturbate? Never Seldom Often Always 6. How many times have you photographed your genitalia and left it for others to see? 7. How many times have you been arrested for an exhibitionism-related offense? Return
1. In what manner do you expose yourself? Passively Aggressively Both 2. How often do you expose yourself to children? Never Seldom Often Always 3. How often do you expose yourself in public? Never Seldom Often Always 4. How often do you expose yourself in private? Never Seldom Often Always 5. How often does your exhibitionism include others watching you masturbate? Never Seldom Often Always 6. How many times have you photographed your genitalia and left it for others to see? 7. How many times have you been arrested for an exhibitionism-related offense?
J) Frotteurism
1. What is your main goal? Have own genitalia stimulated Stimulate other's genitalia Both Neither 2. How often do you rub against others at work? Never Seldom Often 3. How often do you choose children to rub against? Never Seldom Often Always Return
1. What is your main goal? Have own genitalia stimulated Stimulate other's genitalia Both Neither 2. How often do you rub against others at work? Never Seldom Often 3. How often do you choose children to rub against? Never Seldom Often Always
K) Ecouteurism
1. How often do you make obscene phone calls? Never Seldom Often 2. How much money have you spent on calls to phone sex lines in the past year? 3. How often do you listen to others engaged in sexual acts through an internet site? Never Seldom Often Return
1. How often do you make obscene phone calls? Never Seldom Often 2. How much money have you spent on calls to phone sex lines in the past year? 3. How often do you listen to others engaged in sexual acts through an internet site? Never Seldom Often
L) Erotographomania
1. To whom do you write your romantic letters? Strangers Acquaintances Both 2. How often are these acquaintances co-workers? Never Seldom Often Always 3. How do you sign the letters? Anonymously Autographically Both Other 4. How often have your letters led to a negative reaction from the recipient? Never Seldom Often Return
1. To whom do you write your romantic letters? Strangers Acquaintances Both 2. How often are these acquaintances co-workers? Never Seldom Often Always 3. How do you sign the letters? Anonymously Autographically Both Other 4. How often have your letters led to a negative reaction from the recipient? Never Seldom Often
M) Sexual Thievery
1. How often do you enter a victim's residence without permission to obtain items? Never Seldom Often Always 2. Estimate the total monetary value of the items you have stolen: 3. How many times have you been arrested for a sexual thievery-related offense? Return
1. How often do you enter a victim's residence without permission to obtain items? Never Seldom Often Always 2. Estimate the total monetary value of the items you have stolen: 3. How many times have you been arrested for a sexual thievery-related offense?
N) Sadism
1. What type of pain do you inflict? Physical Mental Both 2. How often do you inflict pain on a non-consenting person? Never Seldom Often Always 3. How often do you inflict pain on a child? Never Seldom Often Always 4. How often does the infliction involve mutilation, forced sexual acts or permanent injury? Never Seldom Often Always Return
1. What type of pain do you inflict? Physical Mental Both 2. How often do you inflict pain on a non-consenting person? Never Seldom Often Always 3. How often do you inflict pain on a child? Never Seldom Often Always 4. How often does the infliction involve mutilation, forced sexual acts or permanent injury? Never Seldom Often Always
O) Masochism
1. What type of pain do you receive? Physical Mental Both 2. Who inflicts this pain? Self Other Both 3. How often does the infliction involve mutilation, forced sexual acts or permanent injury? Never Seldom Often Always Return
1. What type of pain do you receive? Physical Mental Both 2. Who inflicts this pain? Self Other Both 3. How often does the infliction involve mutilation, forced sexual acts or permanent injury? Never Seldom Often Always
P) Beastiality
1. What is your main goal? Eroticism Intimacy Both Neither 2. How often does your involvement with animals include forced penetration? Never Seldom Often Always 3. How often does your involvement with animals include injury/death to the animal? Never Seldom Often Always Return
1. What is your main goal? Eroticism Intimacy Both Neither 2. How often does your involvement with animals include forced penetration? Never Seldom Often Always 3. How often does your involvement with animals include injury/death to the animal? Never Seldom Often Always
Q) Stalking
1. Whom do you stalk? Strangers Acquaintances Both 2. How do you choose the people you stalk? 3. What is your main goal? Romance Power/Control Other Unsure 4. How often do you make contact with the victim? Never Seldom Often Always 5. Have you ever had/been threatened with a restraining order for stalking? 1-Yes 2-No6. How many times have you been arrested for a stalking-related offense? Return
1. Whom do you stalk? Strangers Acquaintances Both 2. How do you choose the people you stalk? 3. What is your main goal? Romance Power/Control Other Unsure 4. How often do you make contact with the victim? Never Seldom Often Always 5. Have you ever had/been threatened with a restraining order for stalking? 1-Yes 2-No6. How many times have you been arrested for a stalking-related offense?
R) Molestation
1. How many people have you molested in your lifetime? 2. How many children have you molested? 3. What was the approximate age of the youngest person you have molested? 4. How many mentally retarded, elderly or otherwise incapacitated people have you molested? 5. How many of the molestations have been incestual? 6. Do you still have access to the victims? 1-Yes 2-No If Yes, explain: 7. How often have you used threats, coercion or force to assure the victim's silence? Never Seldom Often Always 8. How many times have you been arrested for a molestation-related offense? 9. On a 0 - 100% scale, how much responsibility for the molestation's do you assume? Return
1. How many people have you molested in your lifetime? 2. How many children have you molested? 3. What was the approximate age of the youngest person you have molested? 4. How many mentally retarded, elderly or otherwise incapacitated people have you molested? 5. How many of the molestations have been incestual? 6. Do you still have access to the victims? 1-Yes 2-No
If Yes, explain:
7. How often have you used threats, coercion or force to assure the victim's silence? Never Seldom Often Always 8. How many times have you been arrested for a molestation-related offense? 9. On a 0 - 100% scale, how much responsibility for the molestation's do you assume?
S) Incest
1. Who were you incestual with? 2. What was the approximate age of the youngest person you were incestual with? 3. How often did you initiate the sexual behavior? Never Seldom Often Always 4. How often was the sexual behavior mutually consented to? Never Seldom Often Always 5. How often have you used threats, coercion or force to assure the victim's silence? Never Seldom Often Always 6. How many times have you been arrested for an incestual-related offense? 7. On a 0-100% scale, how much responsibility for the incestual relationships do you assume? Return
1. Who were you incestual with?
2. What was the approximate age of the youngest person you were incestual with? 3. How often did you initiate the sexual behavior? Never Seldom Often Always 4. How often was the sexual behavior mutually consented to? Never Seldom Often Always 5. How often have you used threats, coercion or force to assure the victim's silence? Never Seldom Often Always 6. How many times have you been arrested for an incestual-related offense? 7. On a 0-100% scale, how much responsibility for the incestual relationships do you assume?
T) Rape
1. How many people have you raped in your lifetime? 2. How often did you rehearse the rapes before attempting? Never Seldom Often Always 3. How often was a weapon/threat of a weapon used during the commission of the rapes? Never Seldom Often Always 4. How often did the rapes include intentional physical injury (non-sexual) to the victim? Never Seldom Often Always 5. How often was the victim drugged, under the influence of drugs or otherwise incapacitated? Never Seldom Often Always 6. How many times have you unsuccessfully attempted to rape someone? 7. How many times have you been suspected of or charged with rape, but not convicted? 8. How many times have you been arrested for a rape-related offense? 9. On a 0 - 100% scale, how much responsibility for the rapes do you assume? Return
1. How many people have you raped in your lifetime? 2. How often did you rehearse the rapes before attempting? Never Seldom Often Always 3. How often was a weapon/threat of a weapon used during the commission of the rapes? Never Seldom Often Always 4. How often did the rapes include intentional physical injury (non-sexual) to the victim? Never Seldom Often Always 5. How often was the victim drugged, under the influence of drugs or otherwise incapacitated? Never Seldom Often Always 6. How many times have you unsuccessfully attempted to rape someone? 7. How many times have you been suspected of or charged with rape, but not convicted? 8. How many times have you been arrested for a rape-related offense? 9. On a 0 - 100% scale, how much responsibility for the rapes do you assume?
U) Other
1. Describe other: Return
1. Describe other:
