CYBERSEX QUESTIONAIRE
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Do you know how to use a computer? ____Yes ____No

Do you rent or own a computer? ____Yes ____No

Do you use a computer at work? ____Yes ____No

Do you have access to the Internet? ____Yes ____No

At home? ____Yes ____No

At work? ____Yes ____No

How many hours per week do you spent online? ______hours/week

At home? ______hours/week

At work? ______hours/week

Do you spend more time on the computer or on the Internet than you intend? ____Yes ____No

Do you feel ashamed or guilty about any of your computer or Internet activities? ____Yes ____No

How often per week are you tempted to act out with the computer? ______/week.

How often per week are you tempted to act out with the Internet? _____The same
amount as with the computer or ______/week.

How often per week do you act out with the computer? ______/week.

How often per week do you act out with the Internet? _____The same
amount as with the computer or ______/week.

Do you visit free pornography sites? ____Yes ____No

Are you a paying member of adults sites? ____Yes ____No

Do you have sexual websites “bookmarked” or have you saved their addresses anywhere? ____Yes ____No

Do you visit chat rooms with adult or pornographic topics or discussion? ____Yes ____No

Do you visit newsgroups with adult or pornographic topics or discussion? ____Yes ____No

Do you use intriguing, flirting, or overtly sexual instant messages (I.M.’s) with people that you met on chat rooms? ____Yes ____No

Do you use anonymous communication to engage in sexual fantasies online? ____Yes ____No

Do you not consider online sexual or romantic “affairs” a violation of your spousal or
partnership commitment? ____Yes ____No

Do you engage in “cybersex,” i.e., sexual exchanges with someone who is also online? ____Yes ____No

Have you moved from “cybersex” to phone sex? ____Yes ____No

Have you arranged to meet someone for a sexual encounter whom you met online? ____Yes ____No

Do you ever fantasize about someone that you met online while having sexual
contact with your off-line partner? ____Yes ____No

Have you ever been caught viewing sexual material on your computer or on the
Internet? ____Yes ____No

Do you have multiple relationships with people online? ____Yes ____No

Are these relationships sexual in any way? ____Yes ____No

Do you use pornography on computer discs or C.D.’s? ____Yes ____No


Negative Consequences:

Has anyone (family, friends, coworkers, boss, or employer) complained about your
use of the computer or the Internet? ____Yes ____No

Has the use of the computer and/or Internet for adult sexual material negativly effected your:
Use of leisure time? ____Yes ____No

Friendships? ____Yes ____No

Couples relationship? ____Yes ____No

Family relationships? ____Yes ____No

Work? ____Yes ____No

Productivity? ____Yes ____No

Do you experience a “high” when engaged in computer or Internet sexual activities? ____Yes ____NoDo you find that you are preoccupied with computer or Internet sexual activities? ____Yes ____No

Do you find that you are _obsessed with computer or Internet sexual activities? ____Yes ____No

Have you developed a tolerance for computer or Internet sexual activities? ____Yes ____No

Have you attempted to cut back on your computer or Internet sexual activities? ____Yes ____No

Have you lost control of your computer or Internet sexual activities? ____Yes ____No

Do you feel compelled to engage incomputer or Internet sexual activities? ____Yes ____No

Have you experienced withdrawal when you cannot engage in computer or Internet sexual activities? ____Yes ____NoHave you experienced cravings for computer or Internet sexual activities? ____Yes ____No

Do you feel physically dependent on engage incomputer or Internet sexual activities? ____Yes ____No

Do you feel psychologically dependent on engage incomputer or Internet sexual activities? ____Yes ____No

Do you experience a personality change when you are engaged in computer or Internet sexual activity? ____Yes ____No

Do you keep your computer or Internet sexual activities secret? ____Yes ____No

Have you engaged in online fantasy activity that would be illegal if it were carried out?
____Yes ____No

Do people on your off-line world know what you do online? ____Yes ____No

Do people on your online world know what you do off-line? ____Yes ____No
What positive efforts have you made to manage your computer and Internet use?

Do you limit your time and activity in any way? ____Yes ____No
How?


Do you use any blocking software like Net Nanny? ____Yes ____No
Which one(s)?


Do you use a special Internet Service Provider (I.S.P.)? ____Yes ____No
Which one?

Do you use online “S” Fellowships? ____Yes ____No
Which ones?


Do you use online recovery communities like AOL’ “Addiction and Recovery”? ____Yes ____No
Which ones?


Do you use listserves? ____Yes ____No
Which ones?


Do you protect yourself from unwanted pornographic spam? ____Yes ____No
How?

Have you ever needed a period of abstinence from the computer or Internet? ____Yes ____No
Why?