Initial intake form

  • Initial intake form

    This form will require approximately 20 mins of your time. Please fill this form out a minimum of 24 hours prior to your designated appointment. Questions that are not a requirement to answer in this form are helpful for your coach if you're comfortable answering them, however not particularly necessary at this point.
  • Format: (000) 000-0000.

  • Relationship & Sex

  • What is your relationship status?
  • Are you experiencing any issues, within your sex life?
  • Do you find it difficult to become or stay aroused with a partner?
  • Do you find it difficult to become, or stay aroused while masturbating?
  • VULVA: Please tick if you experience any of the following:
  • PENIS: Please tick if you experience any of the following:

  • Medical

  • Have you experienced any of the following:
  • Is sex ever painful?
  • Are you pre menopausal or menopausal?
  • Do you or have you previously had cancer?
  • Vulva/vagina: Have/do you experience any of the following?
  • Are you currently pregnant or breastfeeding?

  • Lifestyle

  • Do you consume alcohol multiple times per week?
  • Do you smoke daily?
  • Do you consume marijuana multiple times per week?
  • Do you partake in recreational drugs? (apart from weed)
  • Are you currently, or were you previously(childhood) religious?

  • Goals

  • How would you like your session?

  • Agreements

  • Coaching Contract

    The following represents the Contract between Sincere Sexology& Coaching and the “Client”. The Services contracted shall be that of sexuality & relationship coaching, as set out below (Sincere Sexology & Coaching). Please read it carefully and raise any questions or concerns that you have with me before agreeing to the contract. This agreement will begin upon acceptance by the Client and shall remain valid for the duration of the Client-Coach relationship.  

    The Contract shall be in force for the duration of sessions between Sincere Sexology & Coaching and the client.


    Services

    The services provided by Sincere Sexology & Coaching are generally conducted via telephone, video call, or in person.  Sexuality coaching is a partnership focused on developing the client’s awareness, thinking, and abilities in order to help the client identify and achieve his/her sexuality and relationship-related goals. In coaching conversations, I will be direct and honest and encourage the Client to do the same. The success of the coaching engagement depends upon the Client’s commitment and openness to the process. If the Client believes that sexuality coaching is not working as desired, the Client agrees to communicate this to the Coach. Please note that sexuality coaching should not be used as a substitute for counselling, psychotherapy, sex therapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of diagnosis, treatment or therapy.


    Terms of Coaching

    I invite you to think of Sexuality Coaching as a process. Many people create change for themselves in a short time.  However, refining and sustaining the change takes several sessions.  Although not binding, I ask that you expect our Coaching relationship to last at least three sessions.

     

    Confidentiality

    Sincere Sexology & Coaching fully protects the privacy and confidentiality of its communications with its Clients. At no time will Sincere Sexology & Coaching voluntarily divulge the coaching relationship between themselves and their Clients without written permission from the Clients unless required to do so by law.

    Sincere Sexology & Coaching holds your intake forms in line with HIPAA compliance.

    My Coaching Commitment

             I will always maintain a professional relationship with you.

             I will always keep your interests above those of my own.

             I will maintain, guard and guarantee your confidentiality.

             I will not offer unqualified medical advice, unqualified counselling, or unqualified psychotherapy to you in my duties as a sexuality coach.

             I will never do intentional harm to you.

             I plan to develop a lasting relationship with you built on a foundation of honesty, integrity and respect.

             I commit all my experience, energy and focus to helping you achieve your sexual goals.

             I will communicate clearly.

             I respect your humanity.

             I expect success from every client I serve, and I will not be limited in my expectations by your past failures or past sexual experiences.

             I encourage my clients to believe in their ability as sexual beings, set realistic goals, act, and celebrate success.

             I understand that I am not a therapist, and there will be certain issues that are beyond my scope, and I will help you find the resources that you need.

             I will provide you with a safe and nurturing sexuality coaching experience that will empower them to express themselves sexually without fear of judgment, criticism, or failure.

             I will avoid engaging in any form of pleasure-focused sexual stimulation with you or your partner before, during, or after coaching.

             All of the information that you share shall remain confidential.

             All notes will be kept in a safe and secure place.



    Fees
    Fees are paid in advance of sessions. Payment for Sessions will be made online through PayPal or a Credit/debit card on our website. In the event Client fails to pay any amount due by 24 hours prior to the scheduled session, it may be cancelled at the Sincere Sexology & Coaching’s discretion.

    Fees are non-refundable once coaching has commenced.  Exception: For packages longer than three sessions, if you decide within 48 hours after your first session that sexuality coaching is not for you, I will refund all but the first session fees.  


    Sessions

    At the scheduled appointment time, the coach agrees to call the client at an agreed-upon number or log on to the preferred online form of communication. The Coach and client commit to start and finish each session on time. If the client is more than 10 minutes late for a session, Sincere Sexology & Coaching will assume the session is cancelled, and the client will forfeit the session fee.


    Cancellations

    We ask that you give 24 hours' notice if you need to cancel or change the time of appointment. We will make every effort as well, to re-schedule sessions that are cancelled in a timely manner. Cancellations (less than 24 hours before) and/or no‐show appointments are billed to the client for the full amount.


    Termination of Services

    Either Party may terminate this Agreement immediately upon notice. Notwithstanding the foregoing, Client shall not be relieved of any obligations to pay fees due to Sincere Sexology & Coaching solely because of the termination of this Agreement.

     

    Limitation of Liability

    IN NO EVENT SHALL Sincere Sexology & Coaching BE LIABLE TO CLIENT FOR ANY SPECIAL, PUNITIVE, INCIDENTAL, INDIRECT, OR CONSEQUENTIAL DAMAGES OF ANY KIND IN CONNECTION WITH THIS AGREEMENT. The client understands services provided by Sincere Sexology & Coaching are for support and education only, and no medical advice is provided by Sincere Sexology & Coaching.
    Information provided in sessions or programs written by Sincere Sexology & Coaching's coach/s should not be used as a substitute for medical advice and should only be used as an educational aid and support.

     

    Entire Agreement

    This Contract constitutes the entire agreement between the Client and Sincere Sexology & Coaching, shall not be held responsible and shall remain blameless for any adverse or other consequences, including but not limited to financial, personal, employment or other losses, arising out of decisions or actions the Client may make as a result of the Services provided by Sincere Sexology & Coaching.

     

  • Do you understand the Terms and conditions above?

  • Privacy Policy

    Sincere Sexology & Coaching is committed to providing the highest levels of customer service, including the protection of your privacy. Sincere Sexology & Coachings policies relating to the collection, use and protection of your personal information are outlined in the below statement. 

     

    1. Your Personal Information

    If you decide to book sessions with Sincere Sexology & Coaching or register as a Member, participate in a competition or survey or be included in our mailing list, you are required to provide us with certain information, such as your name, email address, etc. When you book, order or conduct other transactions with us, you generally provide financial details, delivery address and contact details. We are committed to protecting your privacy; Sincere Sexology & Coaching will not sell or distribute your personal information to any other third party. 

    Sincere Sexology & Coaching holds your intake form information in line with HIPAA compliance. 

    2. Security & Protection of Your Personal Information

    Sincere Sexology & Coaching aims to preserve your privacy at all times. We will not disclose your personal information to any third party unless we are required to do so by law or we believe that such action is necessary to: 

    • Comply with the law or with the legal process 

    • Comply with prior permission provided by you to receive special offers via email and/or SMS. 

    • In this instance, your information (email address and/or mobile number) will remain secure and will be used internally by us only to send the relevant information to you. 

    • Protect against misuse or unauthorised use of the Sincere Sexology & Coaching website and other copyrighted materials 

    • Protect the personal safety or property of our customers or the public. 

     

    3. What Is Your Information Used For?

    Your information will be used to:

    • Process your session application with Sincere Sexology & Coaching or register as a Member;
    • Process payments, commissions, and promotions;
    • Process and fulfil your orders and deliveries;
    • Organise promotions;
    • Send you information relating to Sincere Sexology & Coaching and its products;
    • Service and support your Sincere Sexology & Coaching Membership;
    • Generally for the purposes of the Sincere Sexology & Coaching business.


     

    4. Changes to the Privacy Policy

    Sincere Sexology & Coaching reserves the right to change its privacy policy. If we decide to change our privacy policy, we'll post those changes on the website and notify you via our usual channels of communication so you are always aware of how we use and protect your personal information. 

     

    5. How to Contact Us

    If you have any questions or enquiries relating to Sincere Sexology & Coaching privacy policies, practices or procedures, please contact us in one of the following ways:

    M : 0423 790 659

    E : sincerecoaching@outlook.com

     

  • Do you understand & agree to the privacy policy above?
  • Services provided by Sincere Sexology & Coaching are for general support and education purposes only and no medical advice is provided from Sincere Sexology & Coaching? Information provided in sessions, programs and other services should not be used as a substitute for medical advice and should only be used as a support and an educational aid. Do you understand the above statement?
  • Would you like to be emailed about upcoming events, discounts and emailed education/articles?
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