Somatic & Intimacy Education Intake Form

Your Full Name* This field is required.Full name is required, this form is CONFIDENTIAL

First Name

Last Name

Your Email* This field is required.Required, knowing your email is critical since that is how I will communicate with you

example@example.com

Your Email Repeated* This field is required.Required, as you know one little mistake in your email means I can not respond to your intake form

example@example.com

Your Phone NumberRequired

Please enter a valid phone number.

Your Town or City of Residence* This field is required.Optional but its nice to know how far a drive it is for you to get to my studio

Your Year of Birth and Current Age* This field is required.Required as my service is for adults only and so I must verify your legal age

Your Level of Education and SpecializationOptional but it helps me to understand you better and provide better service

Your Current or Former OccupationOptional but it helps me to understand you better and provide better service

Your Current Gender Identity* This field is required.Required, important to know your gender for our sex and intimacy work together

Your Current Sexual Orientation* This field is required.Required, important to know your sexual orientation for our sex and intimacy work together

Your Sexual and Intimate Relationships* This field is required.Please provide as little or as much information that suits your comfort level. Are you married or do you have current partner(s)? Are your sexual and intimate relationships happy ones? Are you looking for support to improve, repair, overcome loss or find a good intimate partner(s) or long-term partner(s) for yourself?

Your Sexual HistoryPease provide as little or as much information that suits your comfort level. How is your current sex life? What has been the joys and difficulties of your sex life over time? Have you been impacted by sexual trauma, repression, guilt or shame? Have you accessed services in the past to address sexual matters in your life?

Your Health StatusYour health information is important to know for sex and intimacy work together. For example, diabetes or other types of illness can impact on sex drive and function. Some medications have sexual side affects. How is your mental health? Please describe any mental health difficulties, neurodiversity or related disabilities.

Sexually Transmitted Infections* This field is required.The focus of our time together is work on supporting your access to healthy sex and intimacy. That includes discussing your history of sexually transmitted infections (STI) and how you typically manage to ensure good health for yourself and your sexual partners. My work with you will include offerings of erotic touch with no exchange of fluids. I use gloves for any internal touch, such as vaginal or anal touch. My use of gloves for genital touch is optional and according to your personal preference. What are your thoughts about managing STI?

Your Interest in Somatic & Intimacy EducationWhich of these following situations apply to you or what sex and intimacy matters are you interested in exploring? Choose as many as you wish.

Feeling lonely and touch deprived and craving human touch experiences

Wishing to experience or learn how to do an erotic massage and spice up your sex life

Seeking general help and teachings to improve current sex and intimate life

Having body image issues, feeling unsatisfied with current body shape, size, etc

Having trouble with sexual dysfunction

Accommodating sexual needs due to a physical, mental, emotional, cognitive disability

Dealing with marriage or long-term relationship that is sexless or involves infrequent sex

Sexual inexperience and looking for sex and intimacy coaching/practice to improve skills

Want to explore gender

Want to explore sexual orientation

Want to explore interest in BDSM and fetishes

Worried about sex addiction or over-dependency on use of pornography

Want help to deal with sexual repression, shame or guilt due to upbringing/conditioning

Want help to deal with sexual trauma

Want more dating confidence and skills to market self accurately, select good prospective partners, have fun dating and be successful in forming new intimate relationships

Have an interest in also exploring the option of a more intensive service called Surrogate Partner Therapy. This is when I act in the role of your temporary intimate partner for a number of months and we work together with a therapist in real-life fashion to help you practice and internalize the skills needed to be successful in forming intimate relationships.

Other Reasons for InterestAre there other more specific sex and intimacy-related matters or problems not listed in the prior frame that you are seeking to address in Somatic & Intimacy Education sessions? if so, you are invited to share your thoughts wth me here or you can choose to wait and speak with me in person about your more specific concerns:

Other Important Information Please think of other information that you think is important for me to know about you. For example, do you have personal, family, cultural or spiritual beliefs that influence your expectations, experiences or views about healthy sexual attitudes and behaviours?

Where Did You Learn About My Service?* This field is required.Please state where you saw my ad or how you came to learn about my practice please so that I know what marketing strategy is the best suited to help spread the word about my service.

Practice Agreements* This field is required.The field of Somatic Sex Education has guidelines for ethical practice set out by our schools that train us and the associations that support our ongoing work. To receive service, clients are required to acknowledge, agree and check off on all these agreements about my practice prior to attending a session. These are applicable to all subsequent sessions as well. So as a client, please indicate that you understand and agree to the following:

This service is an alternative health and wellness service that is therapeutic, but it is not traditional talk therapy. Talk and touch approaches are offered in this modality.

As the client, I can choose to be dressed or undressed in sessions, You, the practitioner and educator, will remain clothed; breasts and genital areas will be covered at all times.

Erotic touch is one-way only, from educator to client. Non-erotic touch is sometimes included in sessions from client to educator, when guided by the educator, for certain learning purposes: negotiating consent in a fuller spectrum, being in loving presence or practice giving wanted touch to partners.

As the client, I agree to refrain from the use of erotic talk during sessions or sexting between sessions, unless I have the express consent of my educator to engage in this activity.

The educator will remain client-focused at all times, sessions are solely for the clients benefit to learn about healthy sex and intimacy. Sessions are not intended to meet the educator's needs for sex and intimacy.

As the client, I will disclose to you, my educator, if I have any health issues or any history, or current accusations, of domestic abuse or sexualized violence that can pose a threat to my educator's health or safety.

As the client, I understand that all matters pertaining to this service are confidential. I understand there are legal circumstances when confidentiality can be overturned by the educator, such as if I pose a danger to myself or others.

As the client, I understand that case matters may be discussed by educators with peers and supervisors for support and learning purposes or used for educational purposes to demonstrate the practice and benefits of modality, but my identity is not revealed.

As the client, I understand that your studio is located in the downtown Winnipeg area.

As the client, I understand that your cell phone number is provided to manage bookings only and not for chatting between sessions. Regular communication is done via email.

Informed Consent for Erotic Touch* This field is required.Please indicate your general awareness that Somatic & Intimacy Education service aims to increase your access to healthy sexual pleasure and healing in your life. It can include both talk and touch -based approaches. When requested and consented, it can include offerings of erotic touch practices for learning purposes. Do you have the intention to include erotic touch practices offered by this modality in your session work?

YESNO

Your Electronic Signature* This field is required.Just type in your name here. I will accept that as your electronic signature

Todays Date* This field is required.

Date

Optional Upload a Photo of Your ID HereFor professional and personal safety reasons, I need to see your government issued ID. I prefer if you upload a photo of your ID here so I can see it prior to booking. It is kept confidential and it is deleted once I check it. Alternatively you can show me your ID at the door at the start of your first session.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Government Issued ID* This field is required.Did you upload a photo of your ID in prior frame? Or will you email your ID to info@wendyscheirich.com? Or will you show me your ID at the start of the first session? I prefer to see it ahead of time, but you can choose the option best suited for your comfort. Your ID is kept strictly confidential.Please tell me here how I will see your ID?

Session Types and Durations (In-Person or Online): Please Choose* This field is required.Option 1) A one-hour Talk-Only Session to connect with me, ask questions, obtain a consult or sex coaching ($150). Option 2) A one-hour Talk & Touch Discovery Session, a sample session for those with time or budget limits ($150) Option 3) A 1.5 hour Talk & Touch Session for clients wanting more learning, relaxation and pleasure time ($225). Option 4) A two-hour Talk & Touch Session; standard for in-person sessions, offers the most learning, relaxation and pleasure time ($300). Please indicate your choice of type and duration:

What Comes Next* This field is required.I will review your intake and send you an email to confirm that I received it. I do have a Confidential Booking Manager and her name is Julie. Julie will be in contact via email to arrange your booking. Julie has admin duties only and does not have access to your intake or other personal information. I prefer weekdays from 10 am to 4 pm. But I can be flexible for evening and weekend time slots. What days/ times are you most often available?