Client Application Form

Client Application Form

Sex + Relationship Therapy
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your intention in applying for Sex + Relationship Therapy?
Are you interested in other services outside Sex + Relationship Therapy?

Tantric Pleasure ExplorationBDSM Senstation PlayBDSM Impact PlayWax PourJust Sex + Relationship Therapy (Talk Session)
Health & Medications
Do you have any significant physical or mental health history/concerns?
Have you received any previous therapy or treatment? (list therapies/treatment)
What method of birth control do you currently use?
If any!
Do you take any conventional medications? (Anti-depressants, Blood Pressure, Hormone replacement, etc.)
Please List
Do you have any Sexually Transmitted Infections?
Lifestyle
How many hours of sleep do you get per night?
on average
What is your occupation?
How would you describe your stress levels?

LowMediumHighVery High
Do you smoke?

YesSociallyPreviously (not anymore)Never
Do you drink?

Regular DrinkerSocial DrinkerRarely DrinkNever Drink
Do you exercise regularly? What exercise?
Have you experienced any significant trauma?
(Sexual assault/Infidelity/Death/Medical trauma/birth)
Relationships
Are you currently in any romantic or sexual relationships/seeing someone?
How satisfied are you in your current relationship?
Do you have children?
(Y/N)
Sex + Self Pleasure
Do you feel sexually satisfied?
Do you masturbate/self pleasure?
Do you use tools/toys? Which ones?
eg. Porn, vibrator, dildo, flashlight, etc.
Thank you for filling out these intake questions!

This information helps me to support you more fully during your session experience.

I look forward to our time together and exploring the fullest sex and relationship desires for you!
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Client Application Form

Health & Medications

Lifestyle

Relationships

Sex + Self Pleasure