Intimacy/Relationship Coach Intake Form

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Name* This field is required.
First Name
Last Name
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Age* This field is required.
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Date of Birth
Date
Month
Day
Year
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Gender
Male
Female
Transgender
Non-binary
Prefer not to say
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Phone Number* This field is required.
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Email* This field is required.
example@example.com
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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The Bahamas
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Cape Verde
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Chile
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Cook Islands
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Cote d'Ivoire
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Marital Status
Single
Married
Divorced
Widowed
9
Occupation
10
Answer only questions that apply to your specific Intimacy/Coaching Needs
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Are you currently taking any medications?
Yes
No
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If yes, then please indicate the medication name and the purpose below:
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Do you have any health condition that you would like to share?
Yes
No
14
If yes, then please share them below:
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Challenging things from your sensual/sexual history that you want me to know are:
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Wonderful things from your sensual/sexual history that you want me to know are:
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Wonderful things about your current sexuality that you want me to know are:
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Please list any medical conditions that affect your sexuality:
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What would you like to tell me about your current intimate relationship/s?
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If you have a partner, do they know that you will be receiving sex coaching? Would you be interested in having them join you for some of the sessions?
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Please tell me about any previous experience with sex therapy and/or sexual bodywork (such as sexological bodywork, sensual massage, sex work, surrogate, tantra, etc.). If you are currently working with a therapist, do they know that you are interested in sex coaching?
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What else would you like me to know about your sexual history or current desire patterns, including gender identity, sexual orientation(s), self-pleasuring practices, fantasies, use of pornography, or any other information that you feel may be important for me to know?
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Please share any experiences you’ve had with sexual assault or trauma that you feel might affect our work together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.
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If relevant, please share any history you have of pregnancy, labor and delivery, miscarriage, or abortion that you feel might affect our working together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.
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How would you like to feel at the end of our work together?
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What questions do you have for me? What would you like to know about sex coaching, my experience and background, or anything else that might affect our work together?
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Will there be anyone else joining you for your coaching sessions and if so, who and have they completed the intake form. What is your desired outcome?
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How long have you and your partner been together? In what form (e.g., dating, living together, married)?
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What is the problem that led you to decide to come to couples Intimacy Coaching?
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What initially attracted you to your partner?
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What was the sex/Intimacy like in the beginning of your relationship?
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Describe your sexual relationship. What do you find most satisfying about it? What don’t you like about it? How has your sexual relationship changed since you were first together?
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What role have you played in contributing to the problems in your relationship Intimacy; what tendencies do you have and what actions have you taken that have helped create or have added to the difficulties between you t wo?
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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 life coach and the client.
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Payment Method
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Please Select
Cash
Credit Card
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How did you find out about our services?
Social Media
YouTube Video
Search Engine
Ads
Other
37
Would you like to receive product updates, news, and promos?
Yes
No
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Intimacy/Sex Coach pricing SessionsFor additional session options contact IndyaPittman@KittyPowerworkshop.com
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ORDER SUMMARY
Total costUSD
Two SessionsYou will be coached for two sessions ( (1hr virtual coaching per session)
$100.00Edit
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Free 30 minute consultation Review intake form and goal setting.
$FreeEdit
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One SessionYou will be coached every week. Minimum of 8 Weeks.
$50.00Edit
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Number of Weeks
Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
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Google Pay
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Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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AppointmentAvaliable Mon -Fri 10am- 9pm| Saturdays and Sundays 10am -11pm EST| *(Please select multiple time sessions)
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