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com
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my goal is:

my target date is:

to reach my goal, i will take these steps:

when I feel like giving up, I will:

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things I’m grateful for:

people I love:

things I’m good at:

fun memories:

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name your emotion:

describe your emotion, or draw a picture:

describe the intensity of your emotion:

describe the quality of your emotion:

describe your thoughts related tyour emotion

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therapist: contact:

therapist: contact:

medical doctor: contact:

dietician: contact:

mentor: contact:

accountability: contact:

support friend: contact:

support friend: contact:

other: contact:

other: contact:

other: contact:

other: contact:

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what happened? describe the situation:

when did this happen & where were you?

why do you think the situation happen?

how did that situation make you feel, both emotionally & physically?

what did you want to das a result of that feeling?

what did you actually d& say?

how did your emotions affect you later?

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breakfast

lunch

dinner

snacks

drinks in your opinion, did you eat healthy today?

how was your overall mood today?

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date situation emotion coping/blocking response

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 I am not good enough I am good enough
I am a bad person I am a good person
I don’t deserve love I deserve love
I am not lovable I am lovable
I am inadequate I am adequate
I am worthless I have value
I am weak I am strong
I am permanently damaged I am healthy (or can be)
I am shameful I have value

I should have done something I did the best I could

I should have known better
I should have done more
I did something wrong
It’s my fault
I do the best I can
I did my best
I did something wrong
I learned from my mistakes
It’s okay to make mistakes

I am not safe I am safe now

I can’t trust anyone I can choose who to trust
I am in danger It’s over I am safe now
I can’t protect myself I can (learn to) take care of myself
I am going to die I am alive right now
It’s not okay to show my emotions I can safely feel & show my emotions

I am not in control I am in control now

I am powerless I have choices now
I am helpless I control my destiny
I am weak I am strong
I cannot be trusted I can be trusted
I cannot trust myself can (learn to) trust myself

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Sometimes we take our pornography use for granted. The purpose of this
checklist is to become absolutely clear about where you currently stand
with pornography.

Describe your most common patterns related to your pornography use.

(For instance- using video, hentai, magazine, etc)

What are your most common triggers for using pornography? ( For
example- Curiosity, Boredom, stress, anxiety, anger, depression, an aid to
masturbation)

What are some of the negative effects of pornography on your life

specifically?

Are there any unusual aspects to your pornography use? ( For instance-
higher than normal frequency, more risky behavior while masturbating.
etc)

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This section covers Fantasies and Romantic Obsessions

Fantasies, in this case, are described as any routine or regular sexual

imaginations. These could occur a few times a day or several times a day,
sometimes stretching out over time, during inappropriate times and may
end in pornography use, masturbation or sex.

Romantic obsessions, in this case, are situations where you fixate on one
person, sometimes a person who you do not personally know and fantasize
about them sexually and romantically for long periods of time. Your fantasy
may involve delusion-where you begin to believe that this person has
similar feelings for you.

What is your history with these two behaviors ( if applicable)?

What are some triggers you experience before engaging in this behavior?

What are some things you do which may be out of the ordinary when
engaging in these behaviors? For instance, going out of your way to be
around this person, collecting pictures of this person, etc.

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TASK M T W TH F SA SU

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* None of the responses to this checklist can be “I don't know”. Encourage
yourself to come up with a response to every question.

1. What are the biggest issues that you are struggling to manage in your
life right now?

2. What are the most important values that you are neglecting in your
life right now?

3. How did you arrive at this point? What was the mental process you
went through that led from your motivation to rebuild your life to
where you are now complacency, hopelessness and apathy?

4. What signs did you observe that could have been warnings that action
needed to be taken before your relapse?

5. How did you react to these signs? Did you ignore them, or take action
that was not effective?

6. What are the consequences of interrupting/ breaking the new values

you have been building?

7. What are some of the new challenges this relapse might have created
in your life?

8. How do you plan to regain your motivation and direction again?

9. What are the steps you are going to take RIGHT NOW to get yourself
back on track?

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This checklist is to be used whenever you experience a strong/powerful
urge.

1. What were your different reactions to this behavior?

For Instance: Fantasized, experience guilt, frustration, try to regain power,

2. Using the scale below, rate your emotional level during the behavior.
3. Emotional Level:
4. Emotional Scale
5. Emotional Level
6. 10: Complete lack of anxiety/stress; Euphoria; Contentment
7. 7 t9: Emotionally Comfortable
8. 5 t7: Mild Anxiety; Irritation; Minor Stressors
9. 3 t5: Moderate Anxiety; Uncomfortable; Bored; Moderate Stressors
10. 1 t3: Considerable Anxiety; Major Stressors
11. 0 and below: Extreme Anxiety; Painful
3. When would have been the best time to make a decision while
experiencing the urge?

4. Identifying this will help you discover when you are most vulnerable
ta relapse in the future.

4. If you relapsed to this urge, now is the time to fix your decision.
1. What was one thing in your life that was negatively affected by your
decision to give in to this urge?
2. What are aspects of behavior that led to this urge that might be a risk
in the

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date situation automatic thought feeling behaviour rational thought

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1. What are all the compulsive behaviors that you have engaged in over
the past week?

- This included acts that do not involve sex or pornography.

2. a. How many hours a week do you estimate that you spent on these
behaviors
b. This past week, how many days have you engaged in your compulsive
behavior?
c. In the past week, how many days have you engaged in multiple
compulsive behaviors?

3 . In the past year, what would you consider to be your top compulsive
habit?
( Example: Masturbating, Fantasizing, Browsing for anonymous sex)

4. How has the intensity, frequency, and length of time that you spend on
your compulsive behavior affected your quality of life over the past
year?

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identify a self-statement that is thoughts & feelings related to the
negative & inaccurate: statement:

what evidence exists that what actual evidence is there rate the extent ( 1 – 10 ) to
this idea is false? for this idea? which you believed it when
you were thinking it:

what is the worst thing that could happen to me?

what can I say to myself to help me reduce false thinking?

rate your belief ( 1 – 10 ) in your rational re-rate your belief ( 1 – 10 ) in your

response: negative self talk:

specify the emotions associated with that self-talk exercise:

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PLACES TGO SERVE OTHERS CHORES

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 1 2 4 5
very 3 slightly very
slightly
dissatisfied neutral satisfied satisfied
dissatisfied

Communication & openness

Resolving conflicts & arguments

Degree of affection & care

Intimacy & closeness

Trust & dependability

Satisfaction w/ your role in

the relationships
Satisfaction with the other
person’s role
Overall satisfaction with
your relationships

total scores >>>

TOTAL SCORE

7- 11 Very dissatisfied

12-18 Slightly Dissatisfied

19-25 Neutral
26-32 Slightly satisfied
33-35 Very satisfied

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 M T W TH F SA SU
Complete in the morning

I went to bed last night at this time:

I got up this morning at this time:

I slept for a total of how many hours?

I woke up during the night how many times?

Complete in the evening

Number of caffeinated drinks today:

Time of last caffeinated drink:

Minutes of exercise completed today:

What I did in the hour before I fell asleep

Mood today? (1=awful, 10=great)

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day I’m thankful for…

10

11

12

13

14

15

16

17

18

19

20

21

22

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day I’m thankful for…

23

24

25

26

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

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 Check the appropriate box after each statement based on what you value.

not somewhat very

important important important value

Beauty & Aesthetics

Change & Variation

Community Life & Citizenship

Creativity

Education & Learning

Family

Financial Freedom

Friends & Social Life

Fun & Enjoyment

Honesty & Integrity

Humor

Intimate Relationships

Parenting

Physical Self-Care & Health

Power & Authority

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 Check the appropriate box after each statement based on what you value.

not somewhat very

important important important value

Recreation & Leisure

Sexuality

Spirituality

Work & Career

Other:

Other:

Other:

Other:

Other:

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 unhealthy behaviors M T W TH F SA SU
Substance abuse

Self-harm

Overspending

Porn/promiscuity

Disordered eating

Lying/manipulating

Stealing/cheating

Avoiding/procrastinating

Violence/fighting

Ruminating

Body-repetitive behaviors

Other:

Other:

Other:

Other:

which behavior did you struggle with the most this week?

are there certain techniques that help prevent you from engaging in these behaviors?

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 rate from 1-10 M T W TH F SA SU
Hostility

Irritability

Phobias

Obsessions

Headaches

Backaches

Irritable bowel

Constipation

Muscle spasms

Insomnia

Depression

Withdrawals

Anger

Resentment

Fears

Neck aches

Indigestion

Ulcers

Diarrhea

Nervous tics

Physical weakness

Low self-esteem

Drinking/drug use
Others

Others

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rate on scale from 1-10 M T W TH F SA SU
depressed

anxious

irritable

angry

lonely

suicidal

disassociated

broken

confused

defeated

empty

tired

bored

needy

distracted

obsessed

hungry

empty

content

social

happy

hyper

elated
wired

hopeful

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rate on scale from 1-10 M T W TH F SA SU
proud

secure

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rate on scale from 1-10 M T W TH F SA SU
Angry

Annoyed

Anxious

Ashamed

Bored

Broken

Burdened

Confused

Content

Defeated

Depressed

Disassociated

Distracted

Elated

Empty

Happy

Hopeful

Hostile

Hungry

Hyper

Irritable

Lazy

Lonely
Loved

Misunderstood

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rate on scale from 1-10 M T W TH F SA SU
Nervous

Obsessed

Overwhelmed

Preoccupied

Proud

Rebellious

Rejuvenated

Secure

Social

Suicidal

Thankful

Tired

Ugly

Useless

Valuable

Weak

Wired

Worthy

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 ACTION STEP/ TASK RESPONSIBILITY DUE

NOTES

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 TITLE: START DATE: DUE DATE:

GOALS / OBJECTIVES

DATE PROJECT MILESTONES

IDEAS/PLANNING

PROJECT TIMELINE

ACTION STEP/ TASK RESPONSIBILITY

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WEEK

DAILY ROUTINES M T W TH F SA SU

WEEKLY ROUTINES
MOTIVATION/REWARDS

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WEEK

DAILY ROUTINES M T W TH F SA SU

WEEKLY ROUTINES
MOTIVATION/REWARDS

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date situation automatic thought feeling behaviour rational thought

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 unhealthy behaviors M T W TH F SA SU
Substance abuse

Self-harm

Overspending

Porn/promiscuity

Disordered eating

Lying/manipulating

Stealing/cheating

Avoiding/procrastinating

Violence/fighting

Ruminating

Body-repetitive behaviors

Other:

Other:

Other:

Other:

which behavior did you struggle with the most this week?

are there certain techniques that help prevent you from engaging in these behaviors?

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breakfast

lunch

dinner

snacks

drinks in your opinion, did you eat healthy today?

how was your overall mood today?

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what emotions do you numb/not feel?

why do you think it’s easier to not feel? how did you learn to numb your emotions?

what do you fear would happen if you felt sadness?

what do you fear would happen if you felt joy?

what do you fear would happen if you felt fear?

what do you fear would happen if you felt anger?

how does being emotionally numb affect your relationships?

what emotions would you like to feel again?

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I feel happy when:

I feel sad when:

I feel excited when:

I feel angry when:

I feel safe when:

I feel scared when:

I feel loved when:

I feel invisible when:

I feel confident when:

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 Physical Symptoms: M T W TH F SA
SU
Stomach pain

Headaches

Back pain

Muscle pain

Joint pain

Other aches/pains

Other:

Other:

Emotional Symptoms: M T W TH F SA
SU
Sad

Worried

Overwhelmed

Distracted

Irritable

Tense / anxious

Other:

Other:

Other: M T W TH F SA
SU
Did you take meds?

Were you active?

Did you eat well?

Menstrual cycle?

Alcohol consumed?

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Other: M T W TH F SA SU

Hours slept – day?

Hours slept – night?

Other:

Other:

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•

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Something I did well today:

Today I had fun when:

I felt proud when:

Today I accomplished:

what do you fear would happen if you felt fear?

Something I did for someone:

I felt good about myself when:

I was proud of someone else:

Today was interesting because:

I felt proud when:

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 M T W TH F SA SU

complete in the morning

I went to bed last night at this time:

I got up this morning at this time:

I slept for a total of how many hours?

I woke up during the night how many times?

complete in the evening

Worried

Number of caffeinated drinks today:

Time of last caffeinated drink:

Minutes of exercise completed today:

What I did in the hour before I fell asleep

Mood today? (1=awful, 10=great)

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When you’re feeling depressed, it can be difficult to complete tasks. Use this sheet to create
simple daily goals

monday afternoon evening

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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