Pornography Use Intake Assessment

Before you begin

Please answer each question as honestly and completely as you can. There are no right or wrong answers. The purpose is to help me understand your history, your pattern and what you have already tried, so that a plan can be built around what is actually true for you. If a question does not apply, write N/A. Your answers are confidential within the bounds of the therapeutic agreement.

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Section A. History and onset

These questions establish the timeline of the behaviour from first exposure to the present day.

At what age were you first exposed to pornography, and how (accidental, peer introduced, sought out)?

At what age did use become regular or habitual, and what was happening in your life around that time?

How has the frequency of use changed over the past ten years (escalating, stable, cyclical)?

How has the type or intensity of content changed over time? Has it escalated in novelty, extremity or category?

Was there a specific event, stressor or life transition that coincided with the pattern taking hold?

Has use ever stopped completely for an extended period (weeks or months)? If so, when, for how long, and what ended that period?

Section B. Current pattern

These questions map what the behaviour looks like right now, in concrete terms.

On average, how many times per week do you currently view pornography?

What time of day does use typically occur?

Where does use typically occur (specific locations or devices)?

How long is a typical session?

Is use typically planned and ritualised, or impulsive and sudden?

Do you combine pornography use with masturbation, or are they sometimes separate behaviours?

Has tolerance occurred, meaning more time, more novelty or more extreme content is needed for the same effect?

Are there days or situations where you use multiple times?

Section C. Triggers

This section identifies the emotional, environmental and relational cues that come before use.

What emotional states most reliably precede use (boredom, stress, loneliness, anxiety, anger, sadness, shame)?

What environmental triggers are present (being alone, specific rooms, specific devices, time of night)?

Are there relational triggers (conflict with a partner, rejection, social isolation)?

Does use happen more after positive events (celebration, reward seeking) or negative ones (escape, numbing)?

Is there a particular time of day or day of week with the highest risk?

Does fatigue or lack of sleep correlate with use?

Is there a point of no return moment you can identify in the lead up sequence?

What thoughts typically occur in the five minutes before use begins?

Section D. Function of the behaviour

These questions explore what psychological need the behaviour is meeting.

What does pornography use give you in the moment (relief, excitement, control, connection, distraction)?

What feeling are you usually trying to avoid or escape?

Does use serve as a substitute for something missing in your life (intimacy, achievement, social connection)?

How do you feel in the first five minutes after use (relief, shame, numbness, regret)?

How do you feel one to two hours after use?

Has pornography use affected sexual functioning, expectations or intimacy with real partners?

Section F. Consequences and impact

How has this affected romantic or sexual relationships?

Has it affected work, sleep or daily functioning?

Has it affected your self esteem or self concept?

Has it created financial costs, for example subscriptions?

Has anyone close to you found out, and how did that affect the relationship?

Has shame or secrecy itself become a maintaining factor (hiding, lying, isolating)?

Section G. Readiness, motivation and resources

On a scale of 1 to 10, how important is it to you right now to stop or significantly reduce use?

On a scale of 1 to 10, how confident are you that you can change, even if you want to?

What is your personal reason for change, and what would life look like if this were no longer a problem?

Who in your life would support you in this process if they knew?

What resources do you currently have available (time, money, support, willingness for therapy homework)?

What does success look like to you: complete abstinence, controlled use or something else?

Section H. Co-occurring factors

Do you experience anxiety, depression or other mental health symptoms currently or historically?

Is there a history of other compulsive or addictive behaviours (substances, gambling, gaming, food)?

Is there a trauma history relevant to sexuality or attachment?

Are you currently taking any medication that may affect mood, libido or impulse control?

Send your answers

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Pornography use intake assessment