Sex & Intimacy Coach Intake Form

Sex & Intimacy Coach Intake Form

Reimagine Sex
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleGender Non-conforming/Non-binaryOther
Preferred pronouns*
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please take the BDSM test at BDSMtest.org. List your top 5 results along with the percentages. *
Marital Status*

SingleMarriedDivorcedWidowed
Occupation*
Are you currently taking any medications?*

YesNo
If yes, then please indicate the medication name and the purpose below:
Do you have any health condition that you would like to share?*

YesNo
If yes, then please share them below:
What are your intimacy goals?*
What are your sex goals?*
What changes would you like to make in your sex life right now?*
What are your sexual insecurities/weaknesses/dislikes?*
What are your sexual strengths/likes?*
What is your sexual boundaries/hard limits?*
What are you willing to do to achieve your goals?*
What are you interested in exploring?*
What are your expectations from these coaching sessions?*
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the coach and the client.

I understand that in order for my coach to best guide and assist me, I need to be honest and transparent.
How did you find out about our services?

InstagramFacebookYouTube VideoSearch EngineReferral/FriendOther
Would you like to receive product updates, news, and promos?

YesNo
Appointment
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