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13. There are times when I am very unhappy.

AI

14. When I drink I usually drink the first


couple of drinks rapidly.
15. My sex life is unsatisfying to me.
16. I hate to plan ahead.

Instructions
The statements in this booklet are personal.
Your answers will be kept confidential. Mark
your answers on your answer sheet. Read each
statement carefully and choose the answer that
applies to you now.
Answer each statement truthfully. Do not give
false information. Your court records may be
reviewed. Any dishonesty will likely be
detected. Do not read anything into these
statements. There are no trick questions.
All statements must be answered.
Section 1
These statements must be answered True or False.
If a statement is true put an X under T for True on
your answer sheet. If a statement is false, put an X
under F for False.
1. Sometimes I worry about what others
think or say about me.

17. Young boys and/or young girls excite me


sexually.
18. I use marijuana (pot).
19. I frequently think about sex.
20. I have a short temper and get angry
quickly.
21. I have strong urges to expose my genitals
(sex organs) to strangers.
22. I have a lot of trouble, pain and worry.
23. Some men and women need to be forced
into sex so they can enjoy it.
24. I am resentful and hostile to authority and
people in general.
25. I have done things when angry or mad
that I regret.
26. My drinking is more than just a minor
problem.
27. I have been told I have a sex problem.

2. I know I drink more than I should.

28. People often tell me I am impulsive.

3. I am worried about my sex life.

29. As an adult, I have been sexually aroused


by a child.

4. I make decisions quickly.


5. I have noticed that many children under
the age of 13 flirt and behave in very
seductive and sexually provocative ways.
6. I have used drugs more than I should.
7. As a child I was curious about sex.
8. I am often angry and resentful of others.
9. I fantasize about exposing my sex organs
(genitals) to strangers.

30. Even though I use drugs, I usually deny


using drugs or say I use less than I really
do.
31. I enjoy watching physically attractive and
sexy people.
32. When somebody hurts or insults me I
usually try to get even.
33. I often think of peoples reactions when I
show them my genitals (sex organs).

10. I am often very lonely and unhappy.

34. I often feel like I am beyond hope or


helpless and should just give up and die.

11. I have obtained sexual pleasure from an


unwilling partner.

35. I have forced someone to have sex with


me.

12. People tell me I am a cold, selfish and


ungrateful person.

36. I have a lot of anger, resentment and


hostility toward others.

Copyright 2009. ALL RIGHTS RESERVED

37. There are times when I am really down,


depressed and discouraged.

57. I have intentionally exposed my genitals


(sex organs) to an unsuspecting stranger.

38. I am concerned about my drinking.

58. No one really cares about me anymore.

39. I am envious of people that have full,


intense and unselfish sex lives.

59. There have been times when I have had


the urge to force someone to have sex
with me.

40. I often act impulsively or without a lot of


thought.
41. I am sexually attracted to children that are
13 years old or younger.
42. When offered drugs I may or may not use
them. It depends on how I feel at the
time.
43. As an adolescent I experimented with sex.
44. I often think about revenge and how I can
get even.
45. I become sexually aroused when I think
about exposing my sex organs (genitals)
to strangers.
46. Recently I have been very discouraged
and depressed.
47. I have done things when sexually aroused
that I regret.

60. People often think I am antisocial because


I am unfriendly, hostile and unsocial or a
loner.
61. There are times I get so angry I cannot
control myself.
62. I worry about being labeled a sex offender
and its impact on the rest of my life.
63. I have a drinking problem.
64. There is something wrong with my sex
life.
65. I often do things without really thinking
them through.
66. As an adult, I have allowed a young child
to touch or fondle my sex organs.
67. Most of my problems with the law and
police have been drug related.
68. I have strong sexual interests and drives.

48. To be honest, I seem to lack gratitude,


sympathy and trust.

69. When angered I am dangerous.

49. Sometimes I get angry or upset at myself.

70. I have masturbated while fantasizing


about exposing my genitals to strangers.

50. I go to Alcoholics Anonymous (AA)


meetings for my drinking problem.

71. I am desperate, miserable and drowning in


a sea of trouble.

51. I often look at nude pictures on the


internet.

72. My sexual urges have led to arguments


and fights with an unwilling partner.

52. I usually do things on the spur of the


moment.

73. People tell me I am antisocial because


they say many of my ideas would be
harmful to society and the public.

53. As an adult, I have sexually touched or


fondled a child.
54. I worry about my use of drugs.
55. There are times when I fantasize about
sex.
56. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Explosive or blow-up
b. Fighting or argumentative
c. Violent or dangerous
d. Lose control or uncontrollable
e. Vengeful or carry a grudge

74. I often feel shaky, jittery or trembling


inside.
75. There are times when I am very
discouraged.
76. When I drink, I often get drunk.
77. I look at child pornography a lot.
78. I often talk before I think.
79. There are times when I am concerned
about my sex life.

Copyright 2009. ALL RIGHTS RESERVED

80. There have been times I have felt guilty


about using drugs.

101. I have a drug problem.

81. As an adult, I have purposely exposed my


sex organs to a preteen youth.

103. I have threatened and physically hurt


someone.

82. To be honest, I am often hostile and


sometimes violent.

104. After I intentionally expose my genitals to


strangers, I leave with no attempt at
having further sexual activity with them.

83. I have used force or the threat of force to


have sexual intercourse.
84. I am often alone and depressed.
85. Most people irritate or annoy me.
86. I have had sexually arousing fantasies that
involve my partner suffering.
87. There are times when I am concerned that
others may think badly of me.
88. I have experienced blackouts (loss of
memory) after drinking heavily.
89. I do a lot of impulsive or unexpected things.
90. I go to Narcotics Anonymous (NA) or
Cocaine Anonymous (CA) meetings for
my drug problem.
91. I have been sexually frustrated.
92. I can be dangerous when frustrated,
insulted or angered.
93. I like the idea that purposely exposing my
sex organs to strangers will get a reaction
out of them.
94. I do not have a support group or anybody
I can talk to.
95. I have never forced anyone to have sex with me.
96. I get upset when others criticize me.
97. I have been treated (counseling or
treatment) for a drinking problem.
98. My intense and recurrent sexual urges are
of concern to me.
99. I like to do things quickly.
100. One or more of the following apply to me
(answer true or false on your answer sheet):
a. Undressing a child and looking
b. Exposing myself to a child
c. Masturbating in a childs presence
d. Gently touching and fondling a child
e. Penetrating a childs mouth, vagina
or anus

102. Sex is important to me.

105. I am greatly disappointed and dissatisfied


with my life.
106. It arouses me even more when my sexual
partner resists.
107. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Cold and indifferent
b. Lying or manipulative
c. Unsympathetic or uncaring
d. Lack of remorse or regret
e. Unreliable or untrustworthy
108. There are times when I am concerned that
others may not approve of me.
109. In the last year drinking has been a
problem for me.
110. I watch pornography on the internet.
111. As an adult, I have had sexual contact
with children.
112. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Sudden or quick
b. Careless or reckless
c. Impatient or hurried
d. Unplanned or spontaneous
e. Not thought out or ill-planned
113. I rarely think or talk about sex.
114. I have acted upon my sexual urges and
fantasies involving children.
115. There are times when it is difficult for me
to control my urges to expose my sex
organs to strangers.
116. I have been physically cruel to some
people and deliberately hurt them.
117. I believe that either partner should be able
to stop foreplay at anytime - even just
before penetration.
118. I often feel friendless, left out and
emotionally isolated or alone.

Copyright 2009. ALL RIGHTS RESERVED

119. People say I am antisocial because I avoid


being close to most people.

134. It bothers me when I am overlooked or


ignored by people I know.

120. Sometimes I really worry about my


responsibilities and happiness.

135. I have little concern or sympathy for


others.

121. To be honest, my life is useless, worthless


and beyond hope.

136. Drinking has interfered with my happiness


and success in life.

122. Fantasies and masturbation have become


my major sexual release.

137. Two or more of the following apply to me


(answer true or false on your answer sheet):
a. Moody and violent temper
b. Unthankful and ungrateful
c. Cheat, trick and steal
d. Lie, mislead and deceive
e. Boastful, irritable and demanding

123. Even though I drink, I usually deny


drinking or say I drink less than I really do.
124. I enjoy sex with children.
125. I like to think things through before I
make decisions.
126. Since I was labeled a sex offender (if not a
registered sex offender skip this item), two
or more of the following apply to me.
a. Difficulty getting and keeping a job
b. Problems keeping close family ties
c. Difficulty moving into a new
neighborhood
d. Very hard to maintain a support group
e. A lifetime burden and hardship
127. I am in counseling or treatment for my
drug problem.
128. I have posted nude photos of myself on
the internet.
129. I have many problems and conflicts with
others.
130. Two or more of the following apply to me
(answer true or false on your answer
sheet).
I expose my sex organs to
strangers in order to:
a. Shock or upset them
b. To sexually arouse them
c. So I can get relief
d. Surprise or astonish
131. Within the last six months I have been
very anxious, depressed and miserably
unhappy.
132. I have been arrested for sexual assault or
rape.
133. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Evasive or secretive
b. Often late paying bills
c. Poor job or work history
d. Heavy alcohol or drug use
e. Repeated problems with the law

138. I have never sexually molested a child.


139. I am at my best when I shoot-from-the-hip
or do things spontaneously.
140. I never daydream or fantasize about sex.
141. People often think my ideas are against
society or could be harmful to others.
142. I have been a patient in two or more drug
treatment programs.
143. I am (or have been) an exhibitionist
because I purposely showed my sex
organs to a stranger.
144. I am (or have been) in sex counseling or
therapy.
145. I am overwhelmed by the pain, misery,
failure and suffering in my life.
146. I often do things impulsively.
147. I have never raped or sexually molested
anyone.
148. My sexual fantasies involve children.
149. I do a lot of unnecessary lying and
conning of others.
150. There are times when I really get angry
and upset at myself.
151. I have masturbated in the last year.
152. I need help to overcome my drinking
problem.
153. My use of drugs has threatened my
happiness and success in life.
154. I have never deliberately exposed my
genitals (sex organs) to a stranger.

Copyright 2009. ALL RIGHTS RESERVED

155. People tell me I have a quick temper and a


bad attitude.
156. More and more I am thinking about death,
dying and suicide.

177. There are times when I just sit and want to cry.
178. I am more angry, hostile and violent than
most people.

157. I manipulate or lie to get what I want.

179. I am concerned about being listed as a


registered sex offender.

158. There have been times when I have been


very concerned about disapproval from
others.

180. I have never had sex with my parent,


grandparent, sister, brother, daughter or
son.

159. I have a lot of disrespect and contempt for


most politicians.

181. I have an explosive and violent temper.

160. My drinking is a serious problem.

182. I am in counseling or treatment for my


drinking problem.

161. I look for sexual partners on the internet.


162. I am an impulsive person.
163. It takes a lot of self-restraint for me to
resist my sexual urges involving children.

183. I meet the definition of a pedophile as I


have had sexual activity with a 13 year
old or younger child.
184. I am a spontaneous or impulsive person.

164. My drug use is more than a minor


problem.

185. There have been times when I have


worried about my sexual performance.

165. I am strongly opposed to many of our


governments rules, regulations, policies
and laws.

186. Drug use is a problem for me.

166. I have felt strong sexual attractions toward


others.

188. I am dependent on drugs and may be


addicted.

167. It is difficult for me to keep close, warm,


and lasting relationships.

189. There is very little, if any, happiness, joy


or pleasure in my life anymore.

168. I often think about sex.

190. I am required to be in sex counseling or


treatment.

169. People tell me I am antisocial because I


choose not to fit in or socialize with most
people.
170. Excluding my spouse (wife or husband) I
have had sex with a member of my
family.
171. There are times when I have been jealous
or resentful of others.
172. To be honest, I am an alcoholic.
173. My sexual adjustment is not normal.

187. I am a violent person.

191. I usually put a lot of thought into the


decisions I make.
192. I really worry about myself and my future.
193. I have a quick temper and get angry
quickly.
194. There are times when I daydream and
fantasize about sex.
195. Sex is not important to me.

174. I often say things I later regret.

196. I need help or I am going to commit


suicide.

175. As an adult, I have never sexually fondled


or had sex with a child under 13 years of
age.

197. I have been convicted of child


molestation.

176. I feel strongly about my opinions and


beliefs, even if others call them antisocial.

198. I am concerned about being called


antisocial or a revolutionary.

Copyright 2009. ALL RIGHTS RESERVED

199. I have been or am in counseling or


treatment because of my molesting a
child.
200. There are times when I am really
depressed.
201. It is important to me that my sexual
partner is satisfied with my sexual
performance.
202. I have been jealous of other peoples
happiness and success.
203. Over the last 6 months or longer, I have
had recurrent, intense and sexually
arousing fantasies about exposing my
genitals (sex organs) to strangers.
204. I have raped someone.
205. I have gone to someone for help with my
drug problem.
206. I have had intense, recurrent sexually
arousing fantasies, sexual urges, or sexual
activity with a 13 year old or younger
child.
207. To be honest, I am antisocial, but still
consider myself a good neighbor and a
patriot.
Section 2
The statements in this section have four answers.
Put an X under the number (1, 2, 3 or 4) on your
answer sheet that represents your answer.
208. How would you describe your drinking?
1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem
209.

210.

How would you describe your drug use?


1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem
How would you describe your temper?
1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem

211. How would you describe your distress?


1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem
212. How would you describe your violence
tendencies or proneness?
1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem
213. How would you describe your sexual
adjustment?
1. A serious problem
2. A moderate problem
3. A slight problem
4. Not a problem
214. How would you describe your desire to
get (or continue) sexual counseling or
treatment?
1. I want help
2. I may need help
3. Maybe, not sure
4. No need
215. During the last six months I have been
very:
1. Distressed
2. Depressed and anxious
3. Both 1 and 2
4. None of the above
216. Recovering means having a substance
(alcohol or other drugs) use or abuse
problem, but not drinking or using drugs
anymore. I am a recovering:
1. Alcoholic
2. Drug abuser
3. Both 1 and 2
4. None of the above
217. During the last six months I have been:
1. Suicidal (dangerous to myself)
2. Homicidal (dangers to others)
3. Both suicidal and homicidal
4. None of the above

Copyright 2009. ALL RIGHTS RESERVED

218. I have forced someone to have sex with


me because:
1. They teased me or led me on
sexually
2. I was under the influence of alcohol
and/or drugs
3. Both 1 and 2
4. None of the above

219. I have forced someone to have sex with


me at least:
1. Once
2. Two or three times
3. Four or more times
4. None of the above

220. How many different sexual counseling or


treatment programs have you been
enrolled in?
1. One or two
2. Three or four
3. Five or more programs
4. None of the above

221. I have been in sexual counseling or sexual


treatment:
1. Less than a year
2. One to three years
3. Four years or more
4. None of the above

223. Rate your sexual adjustment on a scale from 1


to 10. One represents a very good sexual
adjustment and ten represents a very poor
sexual adjustment.
1. Very well adjusted sexually (rating 1 or 2)
2. Average sexual adjustment (rating 3 to 5)
3. Less than average sexual adjustment
(rating 6 to 8)
4. Very poor sexual adjustment (rating 9 or
10)

224. Rate your level of impulsiveness on a scale


from 1 to 10. One represents not
impulsive and ten represents very
impulsive.
1. Not impulsive (rating 1 or 2)
2. Some impulsive (rating 3 to 5)
3. More than average (rating 6 to 8)
4. Very impulsive (rating 9 or 10)

225. Rate your antisocial thoughts on a scale


from 1 to 10. One represents no antisocial
thoughts and ten represents extreme antisocial thoughts.
1. No antisocial thoughts (rating 1 or 2)
2. Some antisocial thoughts (rating 3 to 5)
3. More than average (rating 6 to 8)
4. Extreme or very firm (rating 9 or 10)

222. Rate your level of distress on a scale


from 1 to 10. One represents no distress
and ten represents severe distress.
1. No distress (rating 1 or 2)
2. Some distress (rating 3 to 5)
3. More than average (rating 6 to 8)
4. Severe distress (rating 9 or 10)

0061009

Copyright 2009. ALL RIGHTS RESERVED

AI

Section 1
If a statement is True make a X under T for True.
If a statement is False make an X under F for
False.
T
F
T
F
1. _____ _____
34. _____ _____

First Name:____________________________________

2.

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Middle Initial: _________________________________

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Last Name:____________________________________

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Last 4 Digits of Your Social Security Number:


Age:________________

Sex:_________________

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Date of Birth: _______ / _______ / _______

8.

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Ethnicity (race):_______________________________

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Education (highest grade completed):______________

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Marital Status:________________________________

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1. Age at first conviction: . . . . . . . . . . . . . . _______

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2. Number of times arrested: . . . . . . . . . . . _______

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5. # of sex-related arrests: . . . . . . . . . . . . . _______

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6. # of sexual assault arrests: . . . . . . . . . . . _______

22.

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7. # of child molestation arrests: . . . . . . . . _______

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10. # of alcohol-related arrests: . . . . . . . . . . _______

27.

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11. # of drug-related arrests: . . . . . . . . . . . . _______

28.

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61.

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12. # of months employed in the last 12 months: ____

29.

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66.

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Present or Current Arrest Date:___________________


Todays Date: _______ / _______ / _______
Number (#) refers to the total number in your lifetime.

3. # of times sentenced to prison: . . . . . . . . _______


4. # of violence-related (non-sexual) arrests: ______

8. # of exhibitionism arrests: . . . . . . . . . . . _______


9. # of incest-related arrests: . . . . . . . .....

13. I am a registered sex offender:


True
False
14. I am required to be in sex treatment:
True
False

Copyright Protected. ALL RIGHTS RESERVED.

Section 1, Continued
T
F
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Section 2
The statements in this section have four answers. Put an X under the number (1, 2, 3 or 4) on your answer
sheet that represents your answer.
1
2
3
4
1
2
3
4
1
2
3
4
208. ____ ____ ____ ____ 214. ____ ____ ____ ____ 220. ____ ____ ____ ____
209. ____ ____ ____ ____ 215. ____ ____ ____ ____ 221. ____ ____ ____ ____
210. ____ ____ ____ ____ 216. ____ ____ ____ ____ 222. ____ ____ ____ ____
211. ____ ____ ____ ____ 217. ____ ____ ____ ____ 223. ____ ____ ____ ____
212. ____ ____ ____ ____ 218. ____ ____ ____ ____ 224. ____ ____ ____ ____
213. ____ ____ ____ ____ 219. ____ ____ ____ ____ 225. ____ ____ ____ ____
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