Program Assessment Questionaire

1

A “Values System” is your personal rule book for what is right and what is wrong. This survey helps you to evaluate the degree to which you are acting against your Values System and what level of support you may need to help you be more successful in your choices.

Before filling out the following questionnaire, please make a list of the top 5 ways that you act against your Values System. This could be anything from overeating to looking at pornography.

2

Are you completing this questionnaire for yourself or for someone you care about?

Myself

Someone I care about

3

Are you a wife of someone who is struggling with possible addictions like pornography addiction?

YESNO

4

If you are seeking for help with the effects of betrayal trauma from your marriage, we recommend that you consider the WORTH program for those who are working to save their marriage or WORTH Divorce for those who have decided that divorce is their best option. You can visit www.LifeChangingServices.org/Worth to learn more about the program.

If you would still like to explore other issues you may need help with, click 'Next' to complete the remainder of the Assessment.

5

Since you have indicated that you are completing this for someone you care about, please answer the following questions for them as accurately as possible.

6

This assessment is written in third person. Since you have indicated that you are completing this for yourself, please answer the following questions for yourself as accurately as possible.

7

Does the individual have any recurring behaviors that contradict their values system?

YESNO

8

Based on your answer, we are unable to help this individual with any of Life Changing Services' Programs. The first step to getting support is to recognize that you are acting against your value system. Would you like to try answering the previous question differently?

YES

NO

9

Does it bother the individual that they are acting against their values?

YESNO

10

Based on your answer, we are unable to help you with any of Life Changing Services' Programs. An important step to getting support is to feel some level of regret for your actions. Would you like to try answering the previous question differently?

YES

NO

11

Individual's Gender

Male

Female

12

Individual's age range

Under 18 years old

18 to 23 years old

Older than 23 year old

13

Individual's marital status

Single

Married

14

Are the individual's actions against their value system primarily of a sexual nature (pornography, masturbation, sexual interactions outside their values system)?

YESNO

15

Are the individual's actions against their value system primarily of a self-harming nature (cutting, burning, hitting, etc)?

YESNO

16

How often has the individual acted against their Value System?

Less than 1 every 3 months

Between once every 2 weeks and once every 3 months

More often than once every 2 weeks

IN THE PAST more often than once every two weeks but NOW less than once every 3 months

17

Approximately how many times has the individual seriously committed to themselves that they would not act against their value system, but they have lost again and again anyway?

Less than 3 times in the past 8 weeks

Between 3 and 10 times in the past 8 weeks

More than 10 times in the past 8 weeks

18

Are the individual's actions against their value system primarily anger related (raising voice, sarcasm, name calling, mean words)?

YESNO

19

Are the individual's actions against their value system primarily drug related?

YESNO

20

Are the individual's actions against their value system primarily food/exercise/health related?

YESNO

21

Are the side effects of the individual's actions against their value system having a negative impact on their marital relationship?

YESNO

22

To what degree is the individual's most important relationship(s) still damaged due to a history (past or present) of these actions?

Severely

Moderately

Minor

Not sure

23

Would you like more information on how to win your important Battles?

YESNO

24

Would you like a complimentary consultation regarding training or services that LCS offers regarding the types of Battles you (and/or your loved ones) are fighting?

YESNO

25

Your Name

First Name

Last Name

26

Your First Name* This field is required.

27

Your Last Name

28

Your Email* This field is required.

example@example.com

29

Your Phone Number* This field is required.

Area Code

Phone Number

30

Thanks for completing your assessment. Click Submit to receive your customized report from Life Changing Services.