Sexuality Counseling Pre-Assessment
Chosen Name
*
First Name
Last Name
Pronouns
Gender Identity
*
Gender assigned at birth
Please Select
Male
Female
Intersex
Date of Birth
-
Month
-
Day
Year
Date
Current Psychotherapist
First Name
Last Name
Therapist's Phone Number
Format: (000) 000-0000.
Are you in a relationship?
*
Yes
No
Other
Describe your relationship.
*
(Ex. Single/Uncoupled, Partnered, Open Marriage, Married, Ethically non-monogamous, Polyamorous, etc.)
Do you feel safe in your relationship?
*
Yes
No
Other
Do you experience sexual attraction?
*
Yes
No
Depends
Other
Current Symptoms
Depressed mood
Excessive worry
Impulsivity
Sleep pattern disturbance
Increase risky behavior
Loss of interest
Increased libido
Concentration/forgetfulness
Decrease need for sleep
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Decreased libido
Other
History of physical, sexual, or emotional trauma/abuse?
*
Yes
No
Have you ever needed to exchange sex for basic needs?
Yes
No
Typical Frequency of sex
*
Please Select
Daily
3 x a week
2 x a week
Once a week
Every 2 weeks
Every month
It has been several months
It has been several years
Other
Please list the concern(s) which you are seeking help?
Are you interested in Sexuality Education in addition to Counseling?
Yes
No
Maybe
Family/Support Background and Childhood History:
Do you have children or dependents?
*
Yes
No
Other
List your children or dependents and their ages:
Were you adopted?
Yes
No
Where did you grow up?
List your siblings and their ages:
*
Did your parents divorce?
Yes
No
Personal History
Do you feel safe in your home?
Yes
No
Other
Highest grade completed?
Are you currently:
Working
Student
Unemployed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Do you have any children?
Yes
No
Please list ages and gender:
*
Do you feel safe in your home?
Yes
No
Other
Emergency Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Submit
Submit
Should be Empty: