Sexual Activity Assessment

Sexual Activity Assessment
Chosen Name*

First NameLast Name
Pronouns
Email*
example@example.com
Are you currently in a sexual relationship?*

YesNoHave never been sexually activeWe will discuss
Who are you sexually attracted to? *
(Type of person, gender, etc.)
Which of our services are you interested in?*

Sexuality EducationSexuality Counseling
Approximate number of lifetime sexual partners?*
Do you have children?*

YesNoWe will discuss
Please briefly describe your presenting concern(s):*
How long do you expect to be in counseling in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)?*
What are your goals for counseling?*
Do you feel safe in your relationship?*

YesNoWe will discuss
History of physical, sexual, or emotional trauma/abuse?*

YesNo
Do you feel safe in your home?*

YesNo
Have you ever needed to exchange sex or drugs for basic needs?*

YesNo
Typical frequency of sexual activity**
(Sexual Activity - Any sexual contact with yourself or someone/something else)
I find thoughts about sex with my partner(s) pleasant.

1

2

3

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5

1 is Strongly Disagree, 5 is Strongly Agree
When my partner(s) asks to have sex I readily agree.

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5

1 is Strongly Disagree, 5 is Strongly Agree
When I think about sex I have unpleasant memories *

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1 is Strongly Disagree, 5 is Strongly Agree
When I think about sex I have unpleasant memories. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
Sex disgusts me. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
Sex feels like a chore most of the time.*

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1 is Strongly Disagree, 5 is Strongly Agree
It is easy for me to become aroused. *

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1 is Strongly Disagree, 5 is Strongly Agree
I am usually able to stay aroused throughout sex. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
I am often distracted by other thoughts during sex. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
Our/My sexual activity is rarely rushed. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
Planning time to have sex seems undesirable to me.* *

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1 is Strongly Disagree, 5 is Strongly Agree
I regularly satisfy my partner’s sexual desires.

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1 is Strongly Disagree, 5 is Strongly Agree
My partner(s) regularly satisfies my sexual desires.*

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5

1 is Strongly Disagree, 5 is Strongly Agree
I wish my partner(s) would be more adventurous in bed.

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5

1 is Strongly Disagree, 5 is Strongly Agree
I feel pressured to try new things during sex. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
We (my partners/partner) both usually orgasm during sex.

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5

1 is Strongly Disagree, 5 is Strongly Agree
My partner(s) takes a longtime to orgasm.

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5

1 is Strongly Disagree, 5 is Strongly Agree
I take too long to orgasm. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
I am able to orgasm alone but not with my partner(s).

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1 is Strongly Disagree, 5 is Strongly Agree
I have an active solo-sex life (self-love/masturbation)and I enjoy it.*

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1 is Strongly Disagree, 5 is Strongly Agree
My partner(s) orgasms too quickly.

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1 is Strongly Disagree, 5 is Strongly Agree
I orgasm too quickly. *

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1 is Strongly Disagree, 5 is Strongly Agree
It is a big problem if I or my partner(s) fails to orgasm. *

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5

1 is Strongly Disagree, 5 is Strongly Agree
Our (myself and my partner(s) sex activity usually includes vaginal penetration.

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1 is Strongly Disagree, 5 is Strongly Agree
Vaginal penetration is difficult and/or painful.

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1 is Strongly Disagree, 5 is Strongly Agree
We (me and my partner(s) agree on what makes for good sexual activity.*

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1 is Strongly Disagree, 5 is Strongly Agree
We (me and my partner(s) cannot talk about sexual matters without fighting.

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1 is Strongly Disagree, 5 is Strongly Agree
Overall, I am satisfied with our (me and my partner(s)sex life.

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5

1 is Strongly Disagree, 5 is Strongly Agree
Overall, our (me and my partner(s) relationship is very strong.

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5

1 is Strongly Disagree, 5 is Strongly Agree
Additional comments, questions, or problems not yet noted
How did you hear about us?

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