Set Free Summit Survey

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This is a short survey to help us identify the most common chains holding people hostage to misery, pain, and suffering.

Please answer only for yourself. This survey is completely anonymous.

Chemical Addiction / Substance Abuse

Please check all that apply...

Alcohol

Marijuana

Illegal or prescription drugs

Smoking / Vaping

Chewing

Caffeine

Food Addiction

Please check all that apply...

Junk food or high-fat food

Sugar

Compulsive overeating

Bulimia / Binge eating

Undereating / Anorexia

Mental Addictions / Disorders

Please check all that apply...

Anxiety / Fear

Depression

Bitterness

Anger

Self harm (cutting, suicidal thoughts, etc)

Guilt / Shame

Relationships

Please check all that apply...

Abuse

Unforgiveness

Marital issues

Sex outside of marriage

Gender confusion

Same sex attraction

Parenting struggles

Media / Electronic Addictions

Please check all that apply...

Pornography

Gaming - video games

Social Media

Syncopated music

TV / Movies

YouTube

Obsessions

Please check all that apply...

Gambling / Lottery

Workaholic

Spending / shopping addiction

Sports

Any other addiction(s) you have not listed above?

How long have you had the worst of these addictions?

Less than a year

1 to 5 years

5 to 10 years

10 to 20 years

Over 20

Clear selection

What have you tried that hasn't worked in overcoming these addictions?

Personal will-power / resolutions

Self-help books, videos, or materials

Religious or spiritual practices

Meditation, mindfulness or self-hypnosis

Professional counseling / therapy

Rehabilitation program(s)

Support group(s)

Accountability partner(s)

Prescription drugs

Other:

What specifically do you want freedom from the most?

How badly do you want freedom from this addiction?

I don't care

I'll do anything!

Clear selection

Your age

12 - 19 years old

20 - 29 years old

30 - 39 years old

40 - 49 years old

50 - 69 years old

60+ years old

Clear selection

Your Gender

Male

Female

Clear selection

Do you want us to follow up with you? If so, please provide your name and phone number. This is completely optional.

Submit

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