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Copyright © 2009. ALL RIGHTS RESERVED

SAI Instructions

The statements in this booklet are personal.Your answers will be kept confidential. Markyour answers on your answer sheet. Read each

statement carefully and choose the answer that

applies to you now.

Answer each statement truthfully. Do not give

false information. Your court records may be

reviewed. Any dishonesty will likely be

detected. Do not read anything into thesestatements. There are no trick questions.

All statements must be answered.

Section 1

These statements must be answered True or False.

If a statement is true put an X under T for True onyour answer sheet. If a statement is false, put an X

under F for False.

1. Sometimes I worry about what others

think or say about me.

2. I know I drink more than I should.

3. I am worried about my sex life.

4. I make decisions quickly.

5. I have noticed that many children under

the age of 13 flirt and behave in very

seductive and sexually provocative ways.

6. I have used drugs more than I should.

7. As a child I was curious about sex.

8. I am often angry and resentful of others.

9. I fantasize about exposing my sex organs

(genitals) to strangers.

10. I am often very lonely and unhappy.

11. I have obtained sexual pleasure from an

unwilling partner.

12. People tell me I am a cold, selfish and

ungrateful person.

13. There are times when I am very unhappy.

14. When I drink I usually drink the first

couple of drinks rapidly.

15. My sex life is unsatisfying to me.

16. I hate to plan ahead.

17. Young boys and/or young girls excite mesexually.

18. I use marijuana (pot).

19. I frequently think about sex.

20. I have a short temper and get angry

quickly.

21. I have strong urges to expose my genitals(sex organs) to strangers.

22. I have a lot of trouble, pain and worry.

23. Some men and women need to be forced

into sex so they can enjoy it.

24. I am resentful and hostile to authority and

people in general.

25. I have done things when angry or mad

that I regret.

26. My drinking is more than just a minor

problem.

27. I have been told I have a sex problem.

28. People often tell me I am impulsive.

29. As an adult, I have been sexually aroused

by a child.

30. Even though I use drugs, I usually deny

using drugs or say I use less than I reallydo.

31. I enjoy watching physically attractive and

sexy people.

32. When somebody hurts or insults me I

usually try to get even.

33. I often think of people’s reactions when Ishow them my genitals (sex organs).

34. I often feel like I am beyond hope or

helpless and should just give up and die.

35. I have forced someone to have sex with

me.

36. I have a lot of anger, resentment andhostility toward others.

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37. There are times when I am really down,depressed and discouraged.

38. I am concerned about my drinking.

39. I am envious of people that have full,

intense and unselfish sex lives.

40. I often act impulsively or without a lot of

thought.

41. I am sexually attracted to children that are

13 years old or younger.

42. When offered drugs I may or may not usethem. It depends on how I feel at the

time.

43. As an adolescent I experimented with sex.

44. I often think about revenge and how I canget even.

45. I become sexually aroused when I thinkabout exposing my sex organs (genitals)

to strangers.

46. Recently I have been very discouragedand depressed.

47. I have done things when sexually aroused

that I regret.

48. To be honest, I seem to lack gratitude,

sympathy and trust.

49. Sometimes I get angry or upset at myself.

50. I go to Alcoholics Anonymous (AA)

meetings for my drinking problem.

51. I often look at nude pictures on theinternet.

52. I usually do things on the spur of the

moment.

53. As an adult, I have sexually touched or

fondled a child.

54. I worry about my use of drugs.

55. There are times when I fantasize about

sex.

56. Two or more of the following apply to me

(answer true or false on your answer sheet):a. Explosive or blow-up

b. Fighting or argumentative

c. Violent or dangerousd. Lose control or uncontrollable

e. Vengeful or carry a grudge

57. I have intentionally exposed my genitals(sex organs) to an unsuspecting stranger.

58. No one really cares about me anymore.

59. There have been times when I have had

the urge to force someone to have sex

with me.

60. People often think I am antisocial because

I am unfriendly, hostile and unsocial or aloner.

61. There are times I get so angry I cannot

control myself.

62. I worry about being labeled a sex offender

and its impact on the rest of my life.

63. I have a drinking problem.

64. There is something wrong with my sex

life.

65. I often do things without really thinkingthem through.

66. As an adult, I have allowed a young child

to touch or fondle my sex organs.

67. Most of my problems with the law and police have been drug related.

68. I have strong sexual interests and drives.

69. When angered I am dangerous.

70. I have masturbated while fantasizing

about exposing my genitals to strangers.

71. I am desperate, miserable and drowning in

a sea of trouble.

72. My sexual urges have led to arguments

and fights with an unwilling partner.

73. People tell me I am antisocial becausethey say many of my ideas would be

harmful to society and the public.

74. I often feel shaky, jittery or trembling

inside.75. There are times when I am very

discouraged.

76. When I drink, I often get drunk.

77. I look at child pornography a lot.

78. I often talk before I think.

79. There are times when I am concerned

about my sex life.

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80. There have been times I have felt guiltyabout using drugs.

81. As an adult, I have purposely exposed my

sex organs to a preteen youth.

82. To be honest, I am often hostile and

sometimes violent.

83. I have used force or the threat of force to

have sexual intercourse.84. I am often alone and depressed.

85. Most people irritate or annoy me.

86. I have had sexually arousing fantasies that

involve my partner suffering.

87. There are times when I am concerned thatothers may think badly of me.

88. I have experienced “blackouts” (loss of

memory) after drinking heavily.

89. I do a lot of impulsive or unexpected things.

90. I go to Narcotics Anonymous (NA) orCocaine Anonymous (CA) meetings for

my drug problem.

91. I have been sexually frustrated.

92. I can be dangerous when frustrated,

insulted or angered.

93. I like the idea that purposely exposing mysex organs to strangers will get a reaction

out of them.

94. I do not have a support group or anybody

I can talk to.

95. I have never forced anyone to have sex with me.

96. I get upset when others criticize me.

97. I have been treated (counseling or

treatment) for a drinking problem.

98. My intense and recurrent sexual urges are

of concern to me.

99. I like to do things quickly.

100. One or more of the following apply to me

(answer true or false on your answer sheet):a. Undressing a child and looking

b. Exposing myself to a child

c. Masturbating in a child’s presenced. Gently touching and fondling a child

e. Penetrating a child’s mouth, vagina

or anus

101. I have a drug problem.

102. Sex is important to me.

103. I have threatened and physically hurtsomeone.

104. After I intentionally expose my genitals to

strangers, I leave with no attempt at

having further sexual activity with them.

105. I am greatly disappointed and dissatisfiedwith my life.

106. It arouses me even more when my sexual

partner resists.

107. Two or more of the following apply to me(answer true or false on your answer sheet):

a. Cold and indifferent

b. Lying or manipulativec. Unsympathetic or uncaring

d. Lack of remorse or regret

e.

Unreliable or untrustworthy

108. There are times when I am concerned thatothers may not approve of me.

109. In the last year drinking has been a

problem for me.

110. I watch pornography on the internet.

111. As an adult, I have had sexual contact

with children.

112. Two or more of the following apply to me

(answer true or false on your answer sheet):a. Sudden or quick

b. Careless or reckless

c. Impatient or hurried

d. Unplanned or spontaneouse. Not thought out or ill-planned

113. I rarely think or talk about sex.

114. I have acted upon my sexual urges and

fantasies involving children.

115. There are times when it is difficult for meto control my urges to expose my sex

organs to strangers.

116. I have been physically cruel to some

people and deliberately hurt them.

117. I believe that either partner should be able

to stop foreplay at anytime - even just

before penetration.

118. I often feel friendless, left out and

emotionally isolated or alone.

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155. People tell me I have a quick temper and a bad attitude.

156. More and more I am thinking about death,

dying and suicide.

157. I manipulate or lie to get what I want.

158. There have been times when I have been

very concerned about disapproval from

others.

159. I have a lot of disrespect and contempt formost politicians.

160. My drinking is a serious problem.

161. I look for sexual partners on the internet.

162. I am an impulsive person.

163. It takes a lot of self-restraint for me to

resist my sexual urges involving children.

164. My drug use is more than a minor problem.

165. I am strongly opposed to many of our

government’s rules, regulations, policies

and laws.

166. I have felt strong sexual attractions toward

others.

167. It is difficult for me to keep close, warm,

and lasting relationships.

168. I often think about sex.

169. People tell me I am antisocial because I

choose not to fit in or socialize with most

people.

170. Excluding my spouse (wife or husband) Ihave had sex with a member of my

family.

171. There are times when I have been jealous

or resentful of others.

172. To be honest, I am an alcoholic.

173. My sexual adjustment is not “normal.”

174. I often say things I later regret.

175. As an adult, I have never sexually fondled

or had sex with a child under 13 years of

age.

176. I feel strongly about my opinions and

beliefs, even if others call them antisocial.

177. There are times when I just sit and want to cry.

178. I am more angry, hostile and violent than

most people.

179. I am concerned about being listed as a

registered sex offender.

180. I have never had sex with my parent,

grandparent, sister, brother, daughter or

son.

181. I have an explosive and violent temper.

182. I am in counseling or treatment for my

drinking problem.

183. I meet the definition of a pedophile as I

have had sexual activity with a 13 year

old or younger child.

184. I am a spontaneous or impulsive person.

185. There have been times when I haveworried about my sexual performance.

186. Drug use is a problem for me.

187. I am a violent person.

188. I am dependent on drugs and may be

addicted.

189. There is very little, if any, happiness, joy

or pleasure in my life anymore.

190. I am required to be in sex counseling ortreatment.

191. I usually put a lot of thought into the

decisions I make.

192. I really worry about myself and my future.

193. I have a quick temper and get angry

quickly.

194. There are times when I daydream and

fantasize about sex.

195. Sex is not important to me.

196. I need help or I am going to commit

suicide.

197. I have been convicted of child

molestation.

198. I am concerned about being called

antisocial or a revolutionary.

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199. I have been or am in counseling ortreatment because of my molesting a

child.

200. There are times when I am really

depressed.

201. It is important to me that my sexual partner is satisfied with my sexual

performance.

202. I have been jealous of other people’s

happiness and success.

203. Over the last 6 months or longer, I havehad recurrent, intense and sexually

arousing fantasies about exposing my

genitals (sex organs) to strangers.

204. I have raped someone.

205. I have gone to someone for help with my

drug problem.

206. I have had intense, recurrent sexually

arousing fantasies, sexual urges, or sexualactivity with a 13 year old or younger

child.

207. To be honest, I am antisocial, but still

consider myself a good neighbor and a patriot.

Section 2

The statements in this section have four answers.

Put an X under the number (1, 2, 3 or 4) on youranswer sheet that represents your answer.

208. How would you describe your drinking?

1. A serious problem

2. A moderate problem3. A slight problem

4. Not a problem

209. How would you describe your drug use?


2. A moderate problem3. A slight problem4. Not a problem

210. How would you describe your temper?1. A serious problem

2. A moderate problem

3. A slight problem4. Not a problem

211. How would you describe your distress?1. A serious problem


3. A slight problem

4. Not a problem

212. How would you describe your violence

tendencies or proneness?1. A serious problem



213. How would you describe your sexualadjustment?




214. How would you describe your desire toget (or continue) sexual counseling or

treatment?

1. I want help2. I may need help

3. Maybe, not sure4. No need

215. During the last six months I have beenvery:

1. Distressed

2.

Depressed and anxious

3. Both 1 and 24. None of the above

216. Recovering means having a substance(alcohol or other drugs) use or abuse

problem, but not drinking or using drugs

anymore. I am a recovering:1. Alcoholic

2. Drug abuser

3. Both 1 and 2

4.

None of the above

217. During the last six months I have been:

1. Suicidal (dangerous to myself)2. Homicidal (dangers to others)

3. Both suicidal and homicidal

4. None of the above

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218. I have forced someone to have sex withme because:

1. They “teased me” or led me on

sexually

2. I was under the influence of alcoholand/or drugs

3. Both 1 and 2


219. I have forced someone to have sex withme at least:

1. Once

2. Two or three times3. Four or more times


220. How many different sexual counseling or

treatment programs have you been

enrolled in?1. One or two

2. Three or four

3. Five or more programs4. None of the above

221. I have been in sexual counseling or sexual

treatment:1. Less than a year

2. One to three years

3.

Four years or more


222. Rate your level of “distress” on a scale

from 1 to 10. One represents “no distress”

and ten represents “severe distress.”1. No distress (rating 1 or 2)

2. Some distress (rating 3 to 5)

3. More than average (rating 6 to 8)

4. Severe distress (rating 9 or 10)

223. Rate your sexual adjustment on a scale from 1to 10. One represents a “very good” sexual

adjustment and ten represents a “very poor”

sexual adjustment.

1. Very well adjusted sexually (rating 1 or 2)2. Average sexual adjustment (rating 3 to 5)

3. Less than average sexual adjustment

(rating 6 to 8)4. Very poor sexual adjustment (rating 9 or

10)

224. Rate your level of impulsiveness on a scale

from 1 to 10. One represents “notimpulsive” and ten represents “very

impulsive.”

1. Not impulsive (rating 1 or 2)

2. Some impulsive (rating 3 to 5)3. More than average (rating 6 to 8)

4. Very impulsive (rating 9 or 10)

225. Rate your “antisocial thoughts” on a scale

from 1 to 10. One represents “no antisocialthoughts” and ten represents “extreme anti-

social thoughts.”1. No antisocial thoughts (rating 1 or 2)

2. Some antisocial thoughts (rating 3 to 5)

3. More than average (rating 6 to 8)4. Extreme or very firm (rating 9 or 10)

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SAI First Name:____________________________________

Middle Initial: _________________________________

Last Name:____________________________________

Last 4 Digits of Your Social Security Number:

Age:________________ Sex:_________________

Date of Birth: _______ / _______ / _______

Ethnicity (race):_______________________________

Education (highest grade completed):______________

Marital Status:________________________________

Present or Current Arrest Date:___________________

Today’s Date: _______ / _______ / _______

Number (#) refers to the total number in your lifetime.

1. Age at first conviction: . . . . . . . . . . . . . . _______

2. Number of times arrested: . . . . . . . . . . . _______

3. # of times sentenced to prison: . . . . . . . . _______

4. # of violence-related (non-sexual) arrests: ______

5. # of sex-related arrests: . . . . . . . . . . . . . _______

6. # of sexual assault arrests: . . . . . . . . . . . _______

7. # of child molestation arrests: . . . . . . . . _______

8. # of exhibitionism arrests: . . . . . . . . . . . _______

9. # of incest-related arrests: . . . . . . . .....

10. # of alcohol-related arrests: . . . . . . . . . . _______

11. # of drug-related arrests: . . . . . . . . . . . . _______

12. # of months employed in the last 12 months: ____

13. I am a registered sex offender:True False

14. I am required to be in sex treatment:

True False

Section 1If a statement is True make a X under T for True.

If a statement is False make an X under F for

False. T F T F

1. _____ _____ 34. _____ _____

2. _____ _____ 35. _____ _____

3. _____ _____ 36. _____ _____

4. _____ _____ 37. _____ _____

5. _____ _____ 38. _____ _____

6. _____ _____ 39. _____ _____

7. _____ _____ 40. _____ _____

8. _____ _____ 41. _____ _____

9. _____ _____ 42. _____ _____

10. _____ _____ 43. _____ _____

11. _____ _____ 44. _____ _____

12. _____ _____ 45. _____ _____

13. _____ _____ 46. _____ _____

14. _____ _____ 47. _____ _____

15. _____ _____ 48. _____ _____

16. _____ _____ 49. _____ _____

17. _____ _____ 50. _____ _____

18. _____ _____ 51. _____ _____

19. _____ _____ 52. _____ _____

20. _____ _____ 53. _____ _____

21. _____ _____ 54. _____ _____

22. _____ _____ 55. _____ _____

23. _____ _____ 56. _____ _____

24. _____ _____ 57. _____ _____

25. _____ _____ 58. _____ _____

26. _____ _____ 59. _____ _____

27. _____ _____ 60. _____ _____

28. _____ _____ 61. _____ _____

29. _____ _____ 62. _____ _____

30. _____ _____ 63. _____ _____

31. _____ _____ 64. _____ _____

32. _____ _____ 65. _____ _____

33. _____ _____ 66. _____ _____

Copyright © Protected. ALL RIGHTS RESERVED

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Section 1, Continued

T F T F T F T F

67. _____ _____ 102. _____ _____ 137. _____ _____ 172. _____ _____

68. _____ _____ 103. _____ _____ 138. _____ _____ 173. _____ _____

69. _____ _____ 104. _____ _____ 139. _____ _____ 174. _____ _____

70. _____ _____ 105. _____ _____ 140. _____ _____ 175. _____ _____

71. _____ _____ 106. _____ _____ 141. _____ _____ 176. _____ _____

72. _____ _____ 107. _____ _____ 142. _____ _____ 177. _____ _____

73. _____ _____ 108. _____ _____ 143. _____ _____ 178. _____ _____74. _____ _____ 109. _____ _____ 144. _____ _____ 179. _____ _____

75. _____ _____ 110. _____ _____ 145. _____ _____ 180. _____ _____

76. _____ _____ 111. _____ _____ 146. _____ _____ 181. _____ _____

77. _____ _____ 112. _____ _____ 147. _____ _____ 182. _____ _____

78. _____ _____ 113. _____ _____ 148. _____ _____ 183. _____ _____

79. _____ _____ 114. _____ _____ 149. _____ _____ 184. _____ _____

80. _____ _____ 115. _____ _____ 150. _____ _____ 185. _____ _____

81. _____ _____ 116. _____ _____ 151. _____ _____ 186. _____ _____

82. _____ _____ 117. _____ _____ 152. _____ _____ 187. _____ _____

83. _____ _____ 118. _____ _____ 153. _____ _____ 188. _____ _____84. _____ _____ 119. _____ _____ 154. _____ _____ 189. _____ _____

85. _____ _____ 120. _____ _____ 155. _____ _____ 190. _____ _____

86. _____ _____ 121. _____ _____ 156. _____ _____ 191. _____ _____

87. _____ _____ 122. _____ _____ 157. _____ _____ 192. _____ _____

88. _____ _____ 123. _____ _____ 158. _____ _____ 193. _____ _____

89. _____ _____ 124. _____ _____ 159. _____ _____ 194. _____ _____

90. _____ _____ 125. _____ _____ 160. _____ _____ 195. _____ _____

91. _____ _____ 126. _____ _____ 161. _____ _____ 196. _____ _____

92. _____ _____ 127. _____ _____ 162. _____ _____ 197. _____ _____

93. _____ _____ 128. _____ _____ 163. _____ _____ 198. _____ _____

94. _____ _____ 129. _____ _____ 164. _____ _____ 199. _____ _____

95. _____ _____ 130. _____ _____ 165. _____ _____ 200. _____ _____

96. _____ _____ 131. _____ _____ 166. _____ _____ 201. _____ _____

97. _____ _____ 132. _____ _____ 167. _____ _____ 202. _____ _____

98. _____ _____ 133. _____ _____ 168. _____ _____ 203. _____ _____

99. _____ _____ 134. _____ _____ 169. _____ _____ 204. _____ _____

100. _____ _____ 135. _____ _____ 170. _____ _____ 205. _____ _____

101. _____ _____ 136. _____ _____ 171. _____ _____ 206. _____ _____

207. _____ _____

Section 2

The statements in this section have four answers. Put an X under the number (1, 2, 3 or 4) on your answer

sheet that represents your answer.

1 2 3 4 1 2 3 4 1 2 3 4

208. ____ ____ ____ ____ 214. ____ ____ ____ ____ 220. ____ ____ ____ ____

209. ____ ____ ____ ____ 215. ____ ____ ____ ____ 221. ____ ____ ____ ____

210. ____ ____ ____ ____ 216. ____ ____ ____ ____ 222. ____ ____ ____ ____

211. ____ ____ ____ ____ 217. ____ ____ ____ ____ 223. ____ ____ ____ ____

212. ____ ____ ____ ____ 218. ____ ____ ____ ____ 224. ____ ____ ____ ____

213. ____ ____ ____ ____ 219. ____ ____ ____ ____ 225. ____ ____ ____ ____

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