Tantric Healing Request Form
Thank you for leaning in to learn more about these healing services! Please fill out this entire form and we will reach out to you to discuss your needs and schedule a session! (Serious inquiries only)
Personal Information:
Full Name
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First Name
Middle Name
Last Name
Age
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Occupation
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Gender
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Please Select
Male
Female
Non-Binary
Phone Number
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E-mail
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example@example.com
Questions and Details:
On a scale of 1-10, rate your dating/sex life.
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What's the main reason you'd like to visit Tinkerbella's Temple?
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Have you ever worked with a coach/mentor/tantrika or done therapy, seminars, tantric practice before? (Explain your experience)
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Why is now the time that you decided to reach out and seek support?
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What do you want to accomplish in working together?
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How committed are you to prioritizing this change? (10 being VERY committed)
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Please Select
1
2
3
4
5
6
7
8
9
10
When was the last time you received a professional massage?
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Have you ever received a Tantric Massage? If so, please tell me a bit about your experience and what you received from it.
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Are you a public officer?
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Please Select
Yes
No
Are you willing to submit to a background check?
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Do you have any health limitations that I should be aware of? (physical and/or mental health)
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After reviewing the website and offerings, which one stands out to you as the one that feels the most fitting for what you are desiring to experience?
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What is holding you back from living your dream life?
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Do you live in the 4 Corners Region? If not, are you willing to travel?
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Are you interested in an immersive retreat experience with an optional micro-dose?
Madame only works with clients who are serious about their personal transformation. There is a minimum commitment of 3 sessions ($3,000) and if you are very committed to your transformation, she will grace you with her presence and mentorship for up to 6 months with a combination of video calls and immersive in person somatic ceremony that will change the trajectory of your life. IF YOU DESIRE AN INDIVIDUAL SESSION you will pay a top tier price. If after your conversation Madame~ it is clear that she is the right guide to support you in accomplishing your vision, how much are you prepared to invest in yourself?
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$1,000-$3,000
$3,000-$7,000
$8,000-$15,000
Submit
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