Intake Form-Brief Sexual History

Intake Form-Brief Sexual History

(This confidential questionnaire is required by Dr. Stacy. No information will be shared with anyone other than you, the client, and Dr. Stacy)
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home or Work Phone

Country CodeArea CodePhone Number
Cell Phone*

Country CodeArea CodePhone Number
Ok to call/text or send mail? (Click all that apply)*

Yes mailYes callNo mailYes textNo callNo text but appointment reminders are okOther
Relationship Status:*

SingleMarriedDivorcedSeparatedWidowedPartneredOther
Email:*
Date of Birth:*

MonthDayYear
Date
Anniversary Date (If Applicable)

MonthDayYear
Date
Present Sexual Identity:*

Heterosexual (Straight)GayLesbianPansexualAsexualBisexualOther
Present Gender Identity:*

MaleTransgender MaleFemaleTransgender FemaleNonbinaryOther
Preferred Pronoun:*

He/HimShe/HerThey/ThemOther
Is there anything else you would like me to know about your gender identity, sex or sex characteristics that may become relevant while working together?
Present Living Situation (select all that apply):*

AloneWith FriendsWith RoommateWith Spouse/PartnerWith ParentsWith kidsOther
Brief Sexual History

Please answer these following questions to the best of your ability (estimate if unsure). If any of the questions are answered as "never" or "N/A", please answer with "0" (zero).
Age of 1st Sexual Feeling or Attraction*
Age of 1st Masturbation*
Age of 1st Date*
Age of 1st Sexual Intercourse*
Age of 1st Orgasm *
When was your most recent orgasm? Answer "never" if you haven't had one or put a date or estimated time frame when you last .*
Age of 1st Wet Dream (if N/A enter "0")*
Age of 1st Menstrual Period (if N/A enter "0")*
Age of Menopause (if not yet or N/A enter "0")*
If you are in menopause, what type of hormone supplement used (if any)-RX or natural/OTC? How long has hormone supplement been used? Any sexual concerns due to menopause? (If N/A enter "0")
Write brief answers to the following questions:
1) What childhood messages about sex/sexuality did you receive? Of those, how might they affect your sexuality today?*
2) What are any concerns you may have about your sexuality right now? Meaning why are you here (ex: feelings about your sexual performance, your relationship, low libido, your body, masturbation, etc).*
3) What are any concerns you may have about your gender and/or sexuality? (For example, concerns about being male or female, who you are attracted to, your masculinity, femininity, etc.)*
4) What are concerns you may have about periods or pregnancy? Any concerns about erectile issues or performance anxiety? *
5) What are any concerns you may have about being pre-/peri-/post-menopausal or feelings about your partner being in menopause?*
6) What have been your experiences with achieving orgasm? (Example: How is it alone and/or with a partner)*
7) What have been your experiences with self-pleasuring or masturbating yourself? What is your present pattern and frequency for self-pleasuring/masturbation?*
8) How did and how do you feel about your body (as a child, growing up, as a young adult, now)? *
9) Describe the history of your sexual relationships: (talk about the number of partners, what sexual activities you have experienced, and the issues and conflicts that have emerged for you in intimate relationships.) *
10) Describe any feelings you may have about having sexual contact with your present or possible sexual partner(s): *
11) Describe your present sexual interactions, such as intercourse or masturbation, turn-on’s, your present pattern for sexual pleasure, how often, your current number of partners, etc.: *
12) How often do you think about or desire to have sex?*

Once a dayOnce a weekOnce a month>4x's a day>4x's a weekNeverOnce a yearOther
13) Click below any of these which are sexual “turn-on’s” for you: (click all that apply)*

erotic/porn magazinesmassage parlorsfantasy during masturbationinternet sex (live)prostitutesS&M playcrossdressingswinging clubsexotic dance clubsvoyerismerotic booksromance novelsdirty talkerotic/porn videophone sex linesonline sex chatsOther
14) Are you currently seeing a psychologist/therapist or body worker?*
15) Do you want a referral to a psychologist/therapist or body worker? *
16) Do you have any pre-existing medical conditions that may affect your sexuality? (For example, diabetes, hypertension, heart disease, surgical procedures, depression...) If yes, please explain. Yes or No *
17) Are you currently taking any prescribed medications, such as for hypertension, diabetes, depression, anxiety or cardiovascular disease? Yes or No and which medications (This is to see if these meds may affect your sexual function)*
18) Have you ever had any surgical procedures? If yes, please explain.*
19) Are you interested in learning about and using safe, natural products that can enhance your sexual experience? (Ex: toys, lubes, lotions, etc)*
20) What is your primary, initial, goal for our work together? (Ex: What was your main reason for reaching out)*
21) What are your long-term sexual goals for you as an individual and/or as a couple?*
22) Are you willing to commit to your sexual success, do you agree to do the assignments and allow yourself to open up and enjoy your sexual pleasure? *
23) I hereby release Dr. Stacy Friedman for any damages that may result from sex coaching: *
24) If you found me through a referral, please enter their contact information blanks.

25) If you found me through an online search please share what terms you searched for. blank
26) Write anything else related to your past or present experiences. Include anything that may be important to know that was not already asked, so that I may assist you toward reaching your sexual goals:
Thank you! Dr. Stacy, @ Dr. Stacy Friedman, P.A.

*Payment is required at the time of service. Forms of payment accepted are cash, credit card, Venmo @drstacyfriedman, Zelle and PayPal at stacy@drstacy.org. Payments are non-refundable but can be used for future appointments if necessary.

**If there needs to be communication between you and I that is not in a session or with another provider, physician or therapist that you may refer or recommend a discussion with that exceeds 10 minutes, there is a $60 charge for each 15 minute interval after for that communication.

***Cancellation policy: PLEASE read and sign below. You must contact Dr. Stacy prior to 24 hours of your appointment if you need to cancel or reschedule or you will be charged the full cost of a session. You will automatically receive email reminders 24 hours prior to your appointment so you will know that is the time you need to reach out by. A credit card will be taken at the beginning of the session to keep on file for missed appointments or no shows. Thank you!
Signature: I agree to the payment & the cancellation policy above-*

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