New Client Intake Form Female
Female
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Gender of current partner(s)
Male
Female
Other
Relationship Status
Single
Married
Divorced
Widowed
Number of Children
Number of Pregnancies
Number of Abortions
Number of C-Sections
Number of Miscarriages
Briefly describe your attitudes, thoughts, feelings or perceptions about the following:
Your Body
Sex
Masturbation
Mutual masturbation
Oral sex
Anal sex
Orgasm
Being in a relationship
Being in multiple relationships
Pornography
Sexual role play
Toys and sex accessories
Sexual fantasy
Age of first orgasm
Age of first sexual intercourse
Age of menopause
Check off anything that you are currently experiencing
Lack of arousal
Vaginal dryness
Pain upon intercourse
Difficulty achieving orgasm
Lack of genital sensation
Poor body image
Shame around my sexuality
Fears around sexual contact or activities
Inability to communicate about my sexual needs
Inability to masturbate and satisfy myself
Inability to sexually satisfy my partner
Decreased sense of connection with my partner
Check off any experiences that apply to you in the past or present
Physical abuse
Emotional abuse
Sexual abuse or assault
Experience of breathing difficulties
Motor vehicle accidents
Surgeries (medical/dental)
Problems waking up from anesthesia
Birth or prenatal trauma (if known)
Natural disasters
War/military
How often do you think about or desire to have sex
Please Select
1x a day
2-3 times a day
4+ times a day
1x a week
2-3 times per week
4+ times per week
less than 4 times a month
What is your sex life like now? What would make it better?
What images/fantasies are most likely to arouse you? Describe the most intense point of the fantasy when you are most likely to orgasm.
Describe your most satisfying or exciting erotic/sexual experience? What made it so satisfying/exciting for you?
If you are currently in a relationship, does your partner know your are seeking coaching sessions? If not, please explain.
List any medications you are currently taking (e.g hypertension, diabetes, depression, anxiety, cardio vascular)
What are your long term goals? Where do you see yourself in a year from now?
Difficult things I want you to know about my sexual history:
Wonderful things I want you to know about my sexual history
Check any of the following you are experiencing now or have in the past
low back pain
intense menstrual pain
fibroid/cysts
depression
pelvic/abdominal pain
prolonged bleeding/altered cylces
sexually transmitted disease
UTI/bladder infections
constipation/Irritable bowel snydrome
drug/alcohol abuse
cancer
cigarette smoking habit
Other
Please verify that you are human
*
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