Sexual Activity Assessment

Sexual Activity Assessment
Chosen Name

First NameLast Name
Pronouns
Email
example@example.com
Are you currently in a sexual relationship?
Who are you sexually attracted to?
(Type of person, gender, etc.)
Which of our services are you interested in?
Approximate number of lifetime sexual partners?
Do you have children?
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?
History of physical, sexual, or emotional trauma/abuse?
Do you feel safe in your home?
Have you ever needed to exchange sex or drugs for basic needs?
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.

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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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5

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

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5

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

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5

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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5

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

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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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5

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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5

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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5

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?

Other
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