Embodied Elements SSE/SB Consultation Form

Embodied Elements SSE/SB Consultation Form

For Somatic Sex Education/ Sexological Bodywork Offerings/Sessions. These questions are designed to help through the process of an initial consultation to gather background information for internal purposes only and are kept confidential. The following confidential information will be used to help plan safe and effective sessions.
Personal Information
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Time Zone:
(Pacific Time, CT, ET, etc.)
Email
This will be used to communicate regarding appointments and/or questions you may have.
Client Phone Number
You will not be called/texted unless you have provided consent to do so in the service agreement should you choose to move forward in working with Embodied Elements.
Emergency Contact Name
By filling this out, I give my consent for Embodied Elements, Lucia Vasquez, to contact emergency name listed ONLY in the event of an medical emergency (no individual session details will be disclosed).
Emergency Phone Number
Please enter a valid phone number.

Client Background Information/History
What is your birth sex, gender identity, and sexual orientation if any?
(female, male, intersex, etc.); (Cisgender, Nonbinary, Transgender, Genderfluid, etc.); (bisexual, heterosexual, pansexual, etc.)
Preferred Pronouns if any?
(she/her, he/him, they/them, etc.)
Occupation if any:
Do you have children? If so, how many?
Do you have any medical conditions? Please share details:
On a scale of 1 - 10, how satisfied are you with your current sexual experience/expression?
What area of your sexuality do you currently enjoy the most?
What area of your sexuality do you most want to "work on"? On a scale from 1 - 10, how much sexual/non sexual pleasure do you generally feel/have?
Are you familiar with Somatic Sex Education and/or Sexological Bodywork? If so, please describe:
If you are familiar with this work and have already received hands on Somatic Sexological bodywork sessions, please share any details of when and what type of session you received? Are you interested in de-armoring bodywork or anything else related? Please describe. If not, are you interested in learning more, please describe:
Do you have any scar tissue anywhere on your body? If so, would you be interested in scar tissue remediation?
Please list any areas on the body with scar tissue (small and/or large).
Is there anything that happened recently that inspired you to begin exploring your relationship and/or sexuality? Please describe:
If you could have the greatest sex life/experience, what would that look like?
What's preventing you from having that experience right now?
What do you think your life would be like if you were having the sexual experience, orgasm, and pleasure you desire?
How committed are you to taking action right now to achieve your desires/intentions?
What's one thing that would stop you from taking action right now to achieve your desires/intentions?
Somatic Sex Education/Sexological Bodywork is a trauma informed modality, but Embodied Elements, Lucia Vasquez, is NOT a trauma therapist. Given that these sessions and process are likely to stir up traumas, etc. we want to ensure that you have support systems in place. If you have significant sexual and/or childhood trauma, it is recommended to have sought counseling or are currently in therapy as additional support. Do you currently have a support network available? What does this look like? Please describe:
Please inquire about additional resources and referrals if needed.
In terms of having support to reach your intentions, what appeals to you most:

Consistent, ongoing, long-term supportOnce in awhileGive it all to me now, and let me do my thingOther
Thank you so much for taking the time to share with me, I appreciate you. Is there anything else not already mentioned above that you would like to share with me at this time?
Please check the box to indicate that you understand and agree with the following:
- These questions are designed to help through the process of an initial consultation to gather client history and background information for internal purposes only and are kept confidential. At no given point is information disclosed or shared without client's written consent. This consultation form is stored within the Jotform website and provids end to end encyption for privacy. This means that your submission is kept private and secure.
- This consultation process may stir up trauma and associated memories. You may need additional support to process in the days following the completion of this intake. It is important to ensure you have a reliable support network available. Please inquire about additional resources and referrals if needed.
- You may contact Embodied Elements, Lucia Vasquez, at lvasquez@embodiedelements-wp.com for any questions and/or concerns.
- I understand, have read, and completed this form to the best of my knowlege.
- I give consent for an intial consultation from Embodied Elements, Lucia Vasquez.
- I acknowlege that Embodied Elements, Lucia Vasquez, has the right to terminate the session at any time.
- I understand that withholding information or providing misinformation may result in contraindications and/or irritation from sessions recieved.
- I release Embodied Elements, Lucia Vasquez, from any and all liability associated with any injuries/current and future conditions and assume full responsibility therof.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Embodied Elements SSE/SB Consultation Form

Personal Information