Kali Heart Holistic: Intake Form

Kali Heart Holistic: Intake Form

Letting Me Feel You: A Gentle Beginning Intake Form
Hello beautiful soul,

Welcome.

Please take a few moments to complete this intake form as honestly and fully as feels right for you. There are no wrong answers, and you’re welcome to share as much or as little detail as feels comfortable. Your responses will help me attune more deeply to your unique needs and intentions for our work together, and they will support you in coming into deeper connection with your inner world.

This form is confidential and will only be seen by me. Occasionally, I may seek peer supervision or professional guidance to better support you. In such cases, your identity will remain completely anonymous.

The only exception to confidentiality is if I believe you may be at risk of seriously harming yourself or another. In that case, I may need to reach out for additional support to ensure safety, and I will do so with care and transparency.

Before we begin, it’s important that you are familiar with the scope of this work, so that your expectations and the container we are creating remain aligned.

Scope of Practice

To help you understand the nature of this work, please be aware of the following:
- This offering is rooted in the Embodied Awakening Academy, Tantra Essence and the Shankaracharya Vedic lineages.
- I offer a blend of traditional Tantra, somatic practices, energy work, sacred sexuality, shadow work, breathwork, mindfulness, Vedic Knowledge, traditional counselling, and Reiki.
- In Tantra Counselling, I support clients in awakening the Animal, Heart, and Consciousness centers through conversation, breath, sound, movement, and fully-clothed, consensual touch (excluding any direct genital contact or kissing).
- In Mystic Tantra Massage, I support clients in experiencing peace, total self-acceptance, wholeness and true unconditional love (including direct genital contact with clients' consent).
- This is not therapy or medical treatment. I do not diagnose or treat mental health or physical conditions.
- If trauma or deep emotion arises during our work, I will hold space with care and may refer you to a professional if it falls outside the scope of this practice.
- I do not work with: sexual abuse cases, serious addiction, eating disorders, domestic abuse, complex trauma, chronic medical or psychological conditions, or clients on heavy medications, unless supported by a qualified health practitioner.
- This work is client-led, trauma-informed, and deeply respectful of your pace, boundaries, and inner wisdom.
- You are encouraged to take radical self-responsibility for your journey. I am here to walk beside you, not to fix or rescue.
This is an intake form for:
- Tantra Counselling
- Taoist Tantra Massage
- Kashimiri Tantra Massage
- Inner Alchemy Tantra Massage
- Lasya Tantra Massage
Tantra Counselling supports you to:
- Embody your true sexual power.
- Align with your deepest purpose.
- Embrace the freedom you deserve.
- Go beyond everything you have known so far.
- Commit to fully embody your most authentic self and live your deepest truth.
- Experience true embodiment as a way of life, no longer a concept to grasp, but a living, breathing reality.
- Integrate real clarity, empowerment, and deep awakening into every part of your being.
However, this journey is not for the faint-hearted. It is a shamanic journey of death and rebirth, as you shed what no longer serves you, step into the truth of who you are, and awaken to the legacy you are here to leave. You will heal the parts of you that don’t yet feel safe to receive love, allowing you to become more whole, more present, and more deeply connected to your purpose.

The truth is, deep within you, your power already exists. You already know how to love, to serve, to come fully alive, to experience joy, and to embody the self-love you deserve.

Are you ready to step into a new version of yourself that can effortlessly receive love and abundance, without stress, only ease and pleasure? This initiation will take you there.

In this sacred process, you will:
- Transform your body-mind habits, opening new possibilities for how you show up, relate, and make love.
- Use your body as a transmission of consciousness and love that inspires both your intimate partners and those you work with.
- Become more honest with yourself and others, allowing you to communicate openly and authentically.
- Move from unhealthy masculine/feminine patterns into sacred masculine/feminine embodiment, reconnecting with your inner strength and leadership.
- Release habitual reactivity and embody presence, certainty, and deep listening, allowing you to truly show up in your life and relationships.
- Heighten your energetic and physical sensitivity, allowing you to lead with your heart, mind, and consciousness.
- Release limiting beliefs, turning them into a fresh perspective on how you move through the world.
- Align your thoughts, words, and actions with who you truly are, creating profound clarity and integrity in your life.
- Confidently communicate your needs, desires, and boundaries, standing in your authentic power.
- Drop the walls around intimacy and experience openness as a natural part of your existence.
- Increase your self-worth, stop the cycle of comparison and competition, and stand tall in your value.
- For those who are single: attract a partner who can meet you in their feminine/masculine energy, vulnerability, and authenticity.
- For those who are partnered: deepen the polarity and chemistry with your partner, creating a magnetic connection that is rooted in trust and reverence.
- Give a woman/man what she/he craves, both in and out of the bedroom, becoming a source of deep receptivity and satisfaction.
- Integrate Tantric practices and energy cultivation into your self-pleasure and sexual life, allowing you to experience deeper orgasms, and last longer with pleasure-filled confidence.
Mystic Tantra Massage supports you to:
- Experience peace, total self-acceptance, wholeness and true unconditional love.
- Cultivate honesty, clear expression, open communication, and deep listening to your body's own intelligence.
- Exercise total respect of your values and boundaries.
- Discover a safe, trustworthy, open and caring space where you can be free to express yourself as you are.
- Enhance your awareness and sensitivity.
- Dissolve emotional hurt and confusion.
- Introduce yourself to nonsexual, unbiased, loving, and healing touch.
- Help you to happily and harmoniously stand on your own feet.
- Improve your meditative capacity (ability to stay in the present moment).
- Dissolve sexual patterns, shame, fears, inhibitions, and aftereffects of traumas and abuse.
Genital touch

In the Tantra Counselling practices there is no genital touch of any kind.

In the Taoist Tantra Massage, Kashimiri Tantra Massage, and Inner Alchemy Tantra Massage there is an option to include non-penetrative genital touch with the giver's fingers as part of your massage with the understanding that this touch is an integral part of the whole massage and is aimed at bringing about a state of wholeness to your body, mind, and soul.

In the Inner Alchemy Tantra Massage there is an option to include penetrative genital and/or anal touch with the giver's finger as part of your massage with the same understandings and purposes.

Consent

By filling out this form, you agree and understand that sexual intercourse, genital-genital, oral-oral and oral-genital contact is NOT a part of the Tantra Counselling or the Mystic Tantra Massages. You also understand that the Mystic Tantra Massages are not intended for genital release or ejaculation for either the client or the session giver. As such, the session giver will maintain clear ethical boundaries.

In the Mystic Tantra Massages there is an option to include genital touch with the giver's fingers as part of your massage with the understanding that this touch is an integral part of the whole massage, and is aimed at bringing about a state of wholeness to your body, mind, and soul.

It is ENTIRELY up to you if you would like your session giver to include this aspect of the massage or not. Your session giver will not make any decisions and/or take any actions regarding genital touch without your written consent.

If you have any questions about any of the above, please feel free to reach out.

Thank you for taking the time to read through this form, darling. I look forward to welcoming you soon. 🌸
Do you agree and understand that your Tantra Counselling and/or Mystic Tantra Massage will not include sexual intercourse, genital-genital, oral-oral and/or oral-genital contact, and that genital release or ejaculation are not intended outcomes for the session?*

YesNo
What kind of touch would you like to receive during your Mystic Tantra Massage sessions?*

No, I would not like genital touch of any kind to be included in my massages.No, I will not be receiving massages, only Tantra Counselling.Yes, I would like to include non-penetrative genital touch in my massages.Yes, I would like to include penetrative and non-penetrative genital touch in my massages.Other
General information
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Gender*
Occupation*
City and country of residence*
Phone number*
Email Address*
example@example.com
Emergency Contact*

NameRelationship to you (E.g.: sibling, parent, etc.)
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you find me?
Intention
What is your intention for this work? What do you hope to gain from these sessions?*
What are the main areas in your life you are wanting support with?*
Have you taken action or sought any guidance to improve these issues, and if so, what have you done?*
Overall health
How is your overall health, mentally, emotionally and physically? You will be asked for more details later in the form if you will be receiving Mystic Tantra Massage.*
Do you have any unhealthy habits, coping mechanisms or addictions? If so, what are they? If you have any current addictions (e.g.: sex, porn, alcohol, drugs, smoking, caffeine, painkillers, gaming, phone, etc.), what is your current frequency of use, and amounts consumed.*
Do you have any relevant conditions and/or any medication you are currently on?*

YesNo
Are you currently pregnant and/or trying?*

YesNo
Are you currently under the care of a physician or other healthcare specialist?*

YesNo
Do you have any recent injuries or surgeries?*

YesNo
Do you have any allergies/senstivities?*

YesNo
Please provide details of any medication you are taking and any physical symptoms you are currently experiencing.*
Is it easy for you to say "NO" to people?*

YesNo
Life enjoyment and pleasure
How would you evaluate your life energy level (with 1 being the lowest level, and 10 the highest level)?*

12345678910
How would you evaluate your sexual energy level (with 1 being the lowest level, and 10 the highest level)?*

12345678910
How creative are you (with 1 being the lowest level, and 10 the highest level)?*

12345678910
How much do you enjoy life in general (with 1 being the lowest level, and 10 the highest level)?*

12345678910
How satisfied are you with your sex life (with 1 being the lowest level, and 10 the highest level)?*

12345678910
Is there anything else you would like to share with me?*
⚠️ If not receiving Mystic Tantra Massage, please skip ahead to "Client statement of responsibility and liability waver" at the end of the form.

Mystic Tantra Massage Clients Only
Mystic Tantra Massage: Before and after session guidelines

Receiving these massages is powerful and can bring up memories and emotions. Below are some guidelines to help you understand the process, how to get the most out of a session and to have a more easeful transition after a session.

Please follow these guidelines as a way to give yourself the best opportunity to prepare for and to integrate the sessions into your life.
1. Have a good night's sleep before and after the session. Go to bed early and do not use any mood altering drugs such as alcohol, caffeine, marijuana or sleeping pills for at least 24 hours before and after the session.
2. Drink plenty of pure, clean water before and after the session. This helps to flush toxins out of the body, and supports lubrication, as well as aids the flow of energy.
3. Go for a walk or engage in light exercise before and after the session. If you engage sexually, consider doing so in a slower, more nurturing manner, and do not focus on orgasm or ejaculation.
4. Continue personal practices such as conscious emotional release, breath work, yoga, communication skills, meditation, conscious self touch and self-pleasure exercises, walking in nature and journaling.
5. Do not schedule anything immediately before or after a session, so that you have spacious time to breathe, feel, enjoy and integrate. Oftentimes, clients emerge from their session in a space of silence, meditation, and quiet contemplation, and if that is true for you, then allow yourself that space.
6. Do not engage in sexual union with anyone for at least 2 hours after your session, giving space and time to integrate the powerfully transformative nature of the session.
Personal history and physical state
Have you ever received Mystic Tantra Massage or lingam/yoni massage? If yes, tell me about your experience.
Emotional, relational, and sexual state
Please describe your current emotional state in some detail.
Define your sexuality:

HeterosexualBisexualHomosexualPansexualAsexualQueerQuestioningPrefer not to sayPrefer to self describeOther
What is your current relationship status?

SingleIn a monogamous relationshipIn a polyamorous relationshipMarriedDivorcedSeparatedWidowedIn an open relationshipNon-monogamous (other)EngagedSituationship/exploringPrefer not to sayOther
If you are in at least one relationship, are there any issues present in your relationship? Do they know that you will be receiving Mystic Tantra Massages? What have you told them, and how did they respond?
Describe important experiences in past relationships.
How would you describe your orgasms?

I am multi-orgasmicI experience energetic waves/orgasmsIt is easy for me to have orgasmsI enjoy intimacy, but I do not climaxIt is difficult for me to have orgasms with my partnerIt is difficult for me to bring myself to orgasm without a partnerI can only orgasm from stimulating my clitoris/glans and shaftI can only orgasm by myself in my private spaceI do not feel comfortable touching myself in front of my partnerI do not feel much when I am having sexI am very much in my mind when I am having sexI have not had sex for a long timeI have never experienced an orgasmI have never had sexOther
How do you give yourself sexual pleasure?

With fingers/handWith vibrator/vibrating toysWandI do not engage in self-pleasureOther
Please list previous and current illnesses or medical conditions including STIs, spine injuries and psychological/emotional conditions.
Spirituality/Religion/Beliefs
Do you engage in any spiritual practices?

MeditationYogaTantraPrayerSelf-inquiryBreathworkMindfulnessQigongEmbodimentNoneOther
Have you ever done conscious emotional release (pillow beating, screaming into a pillow, shaking, physical tantrum, etc.)? Please provide more details about your experience with these practices.
Please describe any religious and/or societal conditioning you received regarding sexuality.
Birth and death experiences
Describe what you know of your own birth experience (when your mother gave birth to you).

Natural birth.Orgasmic/ecstatic birth.Traumatic birth.Caesarian section.Epidural anaesthesia or spinal tapEpisiotomy, cut or torn perineumPremature birthUnwanted conceptionIncubatorEarly maternal separationRapid labourSlow labourI do not know anything about my birthNone of theseOther
Have you ever had a near death experience? If yes, please provide more details here.
Is there any other relevant information you would like me to know?
If you are a woman:
Do you experience or have you experienced in the past any of the following?

Numbness (lack of sensibility) in your genitalsPain in your genitalsMenstruation pain/PMSPhysical or mental difficulties with your menstrual cycleLower back painPelvic/abdominal painPain during sexSensitive breastsPain during ovulationLack of lubricationBurning sensations inside the vaginaExtreme sensitivity in genital areaNone of theseOther
If yes, please provide some details.
Do you experience or have you experienced in the past any of the following?

Yeast infectionsUTI/bladder infectionsBacterial vaginosis (BV)STIs - sexual transmitted infectionsNone of theseOther
If yes, please provide some details.
Do you experience or have you experienced in the past any of the following?

CancerHIV - human immunodeficiency virusAIDS - acquired immunodeficiency syndromeHPV - human papilloma virusHSV 1 - oral herpesHSV 2 - genital herpesNone of theseOther
If yes, please provide some details.
Do you experience or have you experienced in the past any of the following?

Haemorrhoid (s)Fibroids/CystsPolypsEndometriosisCervical erosionHormonal imbalanceEating disorderConstipationIrritable bowel syndromeIncontinenceUterine prolapseNone of theseOther
If yes, please provide some details.
At what stage of your life cycle are you now?

MenstruatingPerimenopauseMenopausePostmenopause
Have you have a regular menstrual cycle?

YesNo
Do you have painful periods?

OftenAlwaysSometimesNever
Have you ever had (an) abortion(s)?

YesNo
If yes, at what age(s) and please provide some details.
Have you ever given birth?

YesNo
If yes, at what age?
If yes, how many children do you have?
If you gave birth, did you experience any of these?

Caesarian sectionEpidural anaesthesia or spinal tapEpisiotomy, cut or torn perineumNatural birthOrgasmic/ecstatic birthTraumatic birthStill birthRapid labourSlow labourNone of theseOther
If you gave birth, is there anything you would like me to know about your birthing experience?
Have you ever had a miscarriage?

YesNo
Have you ever had surgery or plastic surgery on your genitals or breasts? E. g.: reshaping of lips, hysterectomy, mastectomy.

YesNo
If yes, please provide some details.
Is there any other relevant information you would like to share?
If you are a man:
Have you ever had an addiction to pornography?

YesNo
If yes, please provide some details.
Do you experience numbness or pain in your genitals?

YesNo
If yes, please provide some details.
Are you circumcised?

YesNo
If yes, at what age and please provide some details.
Do you experience erectile dysfunction?

YesNo
If yes, please provide some details.
Do you experience issues with ejaculation?

Yes, premature ejaculationYes, retard ejaculationNoneOther
If yes, please provide some details.
Is there any other relevant information you would like to share?
Allergies
Do you have any allergies to any of these products?

Coconut oilCocoa butterShea butterAlmond sweet oilApricot oilJojoba oilCetearyl alcoholPEG-20 StearateAloe veraVitamin EPhenoxyethanolEthylhexylglycerinNone of theseOther
For Tantra Massage and Mystic Tantra Massage

Client statement of responsibility and liability waver

Please note that I am here to support you in your embodied awakening. I am not to be relied on in place of your current health care professional or medical doctor and do not advise you to discontinue any medical treatment you may be receiving. My work is intended to be in harmony with any other healing work that you undertake, including traditional medicine.

Sometimes strong emotions, memories or sensations arise and it is up to you (the client) to decide if you want to pause, stop or work through them and release them.

Tantra Counselling and Mystic Tantra Massage sessions are of 1 to 2 hours duration.

Clients have the best results when they commit to packages of multiple sessions:
- 5 Tantra Counselling sessions, or
- 10 Mystic Tantra Massages: 3 Taoist Tantra Massages, 3 Kashimiri Tantra Massages, 3 inner Alchemy Tantra Massages, and 1 Lasya Tantra Massage.
This is recommended because it takes time to build trust, increase body consciousness, surrender and release energy stagnation.

By scheduling a session you agree to take full responsibility for your choices or absence of them. Additionally, you release the practitioner from any liability regarding anything related to the session, physically, emotionally or mentally.

I (the client) verify that:
- All information, provided on this form, is correct and current to the best of my knowledge.
- I understand that any information provided is for safety purposes and will be kept strictly confidential unless I provide written consent.
- I agree to provide full disclosure of my current medical situation, including but not limited to all relevant treatments and medications and that any changes occurring during our sessions, are required to be communicated to my practitioner.
- I understand that the services offered in these sessions are not a substitute for medical care.
- I hereby give my consent to receive treatments and I acknowledge and agree that I am doing so at my own risk.
- My health and safety with respect to such services are my sole responsibility.
- I understand that the session will be facilitated by a Tantra Practitioner, not a medical doctor or therapist. However, a Tantra Practitioner is equipped with the tools to hold me through deep, embodied transformation with loving presence.
- If I experience pain or physical discomfort during the session, or if I am uncomfortable with any part of the session, I will immediately inform my Tantra Practitioner.
- My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith.
- On choosing to engage in sessions I assume personal responsibility to manage my current physical, emotional or mental health conditions.
- In addition, as part of engaging in these sessions, I agree to complete the Client Feedback Forms, in order to support my Tantra Practitioner to better adjust their framework and techniques to my needs.
- I understand that the highest intention of these session is to bring about a profound integration of sexuality and spirituality, supporting a clear flow of Chi (life force) through my body and a sense of oneness in all that I am.
By clicking the "Yes" button below, I acknowledge I have read and agree to the above waiver and conditions and I hereby waive and release my Tantra Practitioner from any and all liability, past, present and future relating to this session work.*

YesNo
Name*

First NameLast Name
Date*

MonthDayYear
Date
Thank you! Wishing you a wonderful session or series of sessions.
See you soon!

Love,

Kali 🌸
Should be Empty:

Kali Heart Holistic: Intake Form

Hello beautiful soul,

This is an intake form for:

Tantra Counselling supports you to:

Mystic Tantra Massage supports you to:

Genital touch

Consent

General information

Intention

Overall health

Life enjoyment and pleasure

⚠️ If not receiving Mystic Tantra Massage, please skip ahead to "Client statement of responsibility and liability waver" at the end of the form.

Mystic Tantra Massage Clients Only

Mystic Tantra Massage: Before and after session guidelines

Personal history and physical state

Emotional, relational, and sexual state

Spirituality/Religion/Beliefs

Birth and death experiences

If you are a woman:

If you are a man:

Allergies

For Tantra Massage and Mystic Tantra Massage

Client statement of responsibility and liability waver