Application - Referral Program

What is you name (First and last)?

What is your age?

What is your email?

How many years has porn/any sex- related addiction been a problem for you?

Where would you place yourself? How much time do you normally go between relapses?

A) Mildly Addicted (I relapse once every 2-4 weeks or less)

B) Moderately Addicted (I relapse every 1-2 weeks)

C) Strongly Addicted (I relapse every 4-6 days)

D) Severely Addicted (I relapse every 1-3 days or more)

Check all of the following symptoms you wish to share with us so we can know your personal situation better.

Living by the emotions of Shame/Guilt

Low Motivation

Depression

Brain Fog

Low self-worth, low self-esteem, low self-confidence

Racing Thoughts

Anxiety (Social anxiety or general anxiety)

Lack of Direction/Purpose

PIED (Porn Induced Erectile Dysfunction)

Difficulty Focusing (easily distracted by the pull of your own thoughts)

Life just feels dull and boring

Difficulty making and/or sticking to goals

Insomnia (difficulty sleeping, or using porn to "help" you fall asleep)

Low Emotional Regulation

Loneliness

Intrusive/unwelcome thoughts (I Imagine pornographic thoughts with the people I'm trying to connect with or interact with)

Difficulty connecting with others in a meaningful way

In what ways will your life improve when you are free from this problem?

In order to get a sense of your current routine, which best describes your current situation?

A) Working: and porn might be affecting my ability for full focus and motivation at work. Possibly effecting my career or even how I interact with coworkers. Help!

C) College Student: Porn interferes with my ability to be a top performing student (Focus, motivation, or possibly social anxiety) Help!

D) College Student and working: And I still find time for porn! Help! I'm drowning!

E) In between jobs and this addiction isn't helping me during this off time! Help!

F) No Work long term. I have WAY too much time to watch porn. Help! (such as on disability or some other reason)

G) Retired and this is not what I wanted my retirement to look like. Help!

If you are willing to share, how much of your finances have you spent on porn and or/sexual services? We find that it's common for men to spend many thousands per year. (your privacy is protected)

On a scale of 1-10, how committed are you to make real changes in your life to be free from this problem? (Commitment means: time investment, emotional investment, and financial investment)

A) Somewhere between 1-7 (I realistically won't do this anytime soon. No one has ever overcome any addiction with a 7 and I'm not ready yet)

B) 8

C) 9

D) 10: The most committed! I will do whatever it takes! I'm Brave! Hold me accountable!

TRUE or FALSE: I currently identify as being addicted to porn/masturbation or hiring escorts and I am looking to find a REAL solution to invest in on how to overcome it.

A) True

B) False

When I find a solution that I know will work for me, then I want to take action:

A) Immediately, because I'm ready and committed to solving this problem no matter what it takes. Im emotionally committed, mentally committed, and financially committed. 👑

B) Maybe within a few weeks or months from now because I'm just not committed to this right now. 🤷🏽‍♂️

C) I'm not 100% sure if I want to quit porn actually. Just being honest. 🤷🏽‍♂️

Phone number to send a text message to if needed for confirmation

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