Thank you for your interest in the Breaking Free Group, a therapy group for men struggling with addictive tendencies to pornography. This questionnaire will give Scott Seibert, the Group Therapist, the information he needs to be sure the group is a good fit for you. All information will be held in strict confidence. Upon review of your responses, Scott may contact you to schedule a personal interview to discuss your needs and answer any questions you may have. Thank you for your honest responses!