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1
Name
*
This field is required.
First Name
Last Name
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2
Email
*
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I will respond personally to serious suitors. Please check your spam folder if you do not see a response, or add hello@embodyempower.com to your contacts.
example@example.com
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3
Phone Number
I encourage you to share a phone number in case my email misses your inbox, but please only share it if it's okay for me to contact you there.
(###) ###-####
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4
Proposed Date and Time
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Year
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Minute
AM
PM
PM
AM
PM
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5
Location
*
This field is required.
Please Select
Incall (This is my preference - I love to host!)
Outcall
Please Select
Please Select
Incall (This is my preference - I love to host!)
Outcall
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6
Outcall Location
*
This field is required.
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7
Type of Date
*
This field is required.
Please Select
The Art of Embodiment
The Art of Receiving
The Art of Giving
The Art of Intimacy
Arrangements & Packages
Please Select
Please Select
The Art of Embodiment
The Art of Receiving
The Art of Giving
The Art of Intimacy
Arrangements & Packages
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8
Date Length
*
This field is required.
Please Select
2 Hours (Recommended first time)
1.5 Hours
1 Hour
Please Select
Please Select
2 Hours (Recommended first time)
1.5 Hours
1 Hour
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9
Date Length
*
This field is required.
Please Select
2 Hours (Recommended first time)
1.5 Hours
1 Hour
Please Select
Please Select
2 Hours (Recommended first time)
1.5 Hours
1 Hour
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10
Date Length
*
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Please Select
About 2 Hours
About 3-4 Hours
5+ Hours (please indicate in message)
Overnight
Full Day
Weekend Getaway
A Week in Paradise
Please Select
Please Select
About 2 Hours
About 3-4 Hours
5+ Hours (please indicate in message)
Overnight
Full Day
Weekend Getaway
A Week in Paradise
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11
Arrangement Type
*
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Please Select
Tantric Journey
Three 2 Hour Sessions (Embodiment, Receiving, or Giving)
Five 2 Hour Sessions (Embodiment, Receiving, or Giving)
Three 4h Dates
Five 4h Dates
Three Overnights
Five Overnights
Please Select
Please Select
Tantric Journey
Three 2 Hour Sessions (Embodiment, Receiving, or Giving)
Five 2 Hour Sessions (Embodiment, Receiving, or Giving)
Three 4h Dates
Five 4h Dates
Three Overnights
Five Overnights
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12
Screening Method
*
This field is required.
Please Select
10 Minute Video Chat - $50 paid upfront
Provider References
LinkedIn & a Selfie
Photo ID & a Selfie
Please Select
Please Select
10 Minute Video Chat - $50 paid upfront
Provider References
LinkedIn & a Selfie
Photo ID & a Selfie
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13
Payment Type
*
This field is required.
I will send you the instructions for the option you choose.
Please Select
CashApp
Venmo
Amazon Gift Card
Bitcoin
Please Select
Please Select
CashApp
Venmo
Amazon Gift Card
Bitcoin
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14
Provider References
*
This field is required.
Please provide as much information as you can for 1-2 providers who have given you permission to use them as a reference. Along with an email and/or phone number, they must have a website, twitter/social media presence, and ad, to show they are established.
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15
LinkedIn
*
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Your LinkedIn Profile URL
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16
Photo ID
*
This field is required.
You may cover or blur information besides your name and address.
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Max. file size
: 10.6MB
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Selfie
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17
Selfie
*
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Please share a recent selfie.
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Max. file size
: 10.6MB
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Selfie
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18
Message
*
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I'd love to learn a little about you (for example, your name, interests, work, age, where you're from or what brings you to town), and your intentions for our time together (e.g. what you're most hoping to get out of this experience, what made you want to reach out, or an idea for a date). A thoughtful message is the best way to get my attention!
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19
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