New Client Intake Form Female

New Client Intake Form Female

Female
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
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
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 *
Should be Empty: