Recovery Workshop

Life Assessment

General Information:

Life Assessment #:
User Name:
E-mail address:

1. In relation to your general mental health, summarize your progression/regression over the past thirty days:

2. Document your experiences with the following:

Behavior	Past 30 Days # of Times	Past 30 Days Hours Engaged
A) Masturbation
B) Pornography
C) Promiscuity
D) Transvestism
E) Fetishism
F) Erotic Fantasy
G) Prostitution
H) Exhibitionism
I) Voyeurism
J) Frotteurism
K) Ecouterism
L) Erotographomania
M) Sexual Thievery
N) Sadism
O) Masochism
P) Beastiality
Q) Stalking
R) Molestation
S) Incest
T) Rape
U) Other

3. Using the scale below, rate the positive impact that your recovery efforts over the past thirty days have had on your:
(1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)

Family	(1-5)
Friends	(1-5)
Co-workers	(1-5)
Career	(1-5)
Finances	(1-5)
Romantic Relationships	(1-5)
Self-esteem	(1-5)
Stress level	(1-5)
Time management	(1-5)
Hobbies	(1-5)

4. Using the scale below, rate the negative impact that your sexual and/or romantic behaviors over the past thirty days have had on your:
(1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)

Family	(1-5)
Friends	(1-5)
Co-workers	(1-5)
Career	(1-5)
Finances	(1-5)
Romantic Relationships	(1-5)
Self-esteem	(1-5)
Stress level	(1-5)
Time management	(1-5)
Hobbies	(1-5)

5) Summarize the progress made towards your existing recovery and life goals over the past thirty days:

6) Describe the closest you came to a slip/relapse over the past month:

7) List the most likely relapse triggers you will face in the coming month:

8) Approximate (in percentages) the amount of time over the past month that you have spent:

Engaged in value-based (top three values) activity
Engaged in value-based (top ten values) activity
Engaged in emotion-based, unhealthy Activity
Life Maintenance Chores*
With Family (Quality)
With Friends (Quality)
Alone (Quality)
Engaged in Unhealthy Sexual Behavior
Engaged in Unhealthy Romantic Behavior
Self-Improvement/Recovery

* Cooking, cleaning, laundry, mowing the lawn, etc

9) Overall, how would you rate your emotional state over the past thirty days:

a) At it's healthiest:
b) At it's unhealthiest:
c) Overall: