Lotus Love Tantra Intake Form

Lotus Love Tantra Intake Form
Section 1: Welcome & Personal Information
Welcome to my Practice. Thank you for choosing to step into this sacred work. I'm honored you're here. This Intake Form is an invitation for you to begin sharing yourself with me. Everything you share—whether through this form, in session, or via email, phone, or text—is held confidentially. The only exception is for professional supervision, and even then, your identity is protected with utmost care.

Please respond to each question as if you were writing in your journal or speaking to someone you trust deeply. There are no right or wrong answers—only what is true for you right now. Don’t worry about getting it “perfect.” Just be real. The more honest and open your responses, the more effective our work together can be. Thank you for your willingness to share. It is truly a privilege to walk beside you on this journey.
Today’s Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone
Preferred method of Communication outside of session

EmailTextPhone
Best times to reach you
Current Address (Street, City, State, Country, Zip)
Date of Birth

MonthDayYear
Date
Place of Birth
Time of Birth

Hour Minutes

AM/PM Option
Emergency Contact Name and Number
How did you find/hear about me?
Section 2: Identity and Work
What is your current work/school situation?
Occupation or Field of Study
Genital Anatomy at Birth

FemaleMaleHermaphrodite
Current Genital Anatomy (if different than at birth)
Gender Pronoun/Identification

She/HerHe/HimThey/Them
How do you describe your gender identity?
How do you describe your current relationship status?
What is your sexual preference?
Section 3: Primary Relationships
Describe your relationship with each member of your family (Father, Mother, Siblings, anyone else significant from your childhood)
Do you have children?

YesNo
If so, please list their names, ages, and briefly describe your relationship with each.
Are you currently in a relationship?

YesNo
If yes, how is this relationship for you?

Happy and HarmonicContentChallengedIn Trouble
Briefly describe past and present dynamics
Does your partner know you are contacting me?

YesNo
Are they open to Tantra?

YesNoDon't know
What inspired you to contact me?
What is your prior relationship experience?
Do you see any recurring patterns?
Anything else I need to know about your current of past intimate relationships?
Section 4: Physical & Sexual Health
Describe your current physical and sexual health.
Any physical injuries or limitations?

YesNo
If yes, please describe
Any recent surgeries?

YesNo
If yes, please list/describe
Do you have any environmental allergies or sensitivities (not food) but animals, especially cats, pollen, scents, etc?
Have you been vaccinated for COVID 19?

YesNo
Boosted?

YesNo
Dates of Vaccinations (if known)

MonthDayYear
Date
Dates of Vaccinations (if known)

MonthDayYear
Date
Dates of Vaccinations (if known)

MonthDayYear
Date
Anything I should know about your physical body?
Are you currently on or have you recently been taking ANY medication for a physical condition?

YesNo
Please list any medications that you are currently taking or have taken for longer than three months, including your dosage and when you discontinued them if you no longer take them.

	Drug	Dosage	Date Begun	Date Stopped

Diagnosed with clinical depression or any mental health condition?

YesNo
If yes, have you been prescribed medication? If so, please include in the list above.

YesNo
Do any medications you're taking affect your libido?

YesNo
History or current exposure to STI's/STD’s?

YesNo
When were you last tested and what were the results?
Section 5: Background & Practices
Experience with therapy and/or meditation?
Any known history of emotional, physical, or sexual abuse?

YesNo
If yes, share what you feel comfortable sharing
Have you had or do you have any addiction?

YesNo
If yes, what kind? How have you addressed or denied it?
Traumas or challenges during childhood/teens/adulthood?
Ever experience low motivation, hopelessness, or low energy?

YesNo
Have you ever done yoga?

YesNo
If yes, what kind and describe your practice
Understanding of and experience with Tantra
Religious background and current spiritual beliefs
Do you have background in meditation or spiritual disciplines?

YesNo
If yes, please describe
Which types of orgasms have you experienced with yourself? (Check all that apply)
ClitoralVaginalCervicalBlended (Clitoral and Vaginal at the same time)Ejaculatory MenEjaculatory Women ("Amrita")AnalProstaticFull BodyMultipleG-Spot/Sacred Spot
Which types of orgasms have you experienced with a partner? (Include both your own experiences and, if known, your partner’s)
ClitoralVaginalCervicalBlended (Clitoral and Vaginal at the same time)Ejaculatory MenEjaculatory Women ("Amrita")AnalProstaticFull BodyMultipleG-Spot/Sacred Spot
Have you ever experienced Sacred Spot Massage or "G-spot Massage"?

YesNo
What do you usually say, do, feel, or experience when you orgasm?
Describe your relationship to self-pleasuring (masturbation)
Describe your relationship to any form of erotic expression that you have explored or desire to explore
7: Life Inventory

Please rate how you feel in the following areas of your life 1=extremely uncomfortable/an area you’re wanting to focus on 5=extremely comfortable/nothing you wish to change. Feel free to add comments to flesh out your answers if you wish
Emotional Health
Emotional Health
Physical Health
Physical Health
Mental Health
Mental Health
Personality / Ego
Personality / Ego
Creativity / Purpose
Creativity / Purpose
Relationships with Others
Relationships with Others
Finances / Abundance
Finances / Abundance
Body / Sexuality
Body / Sexuality
Spirituality
Spirituality
Recreation / Play / Fun
Recreation / Play / Fun
Community / Belonging
Community / Belonging
Other areas of challenge or desire for growth?
Anything you feel is missing or that you long for?
Section 8: Intentions & Availability
What recurring issues and challenges are coming up in your life that you'd like to address?
What kind of exploration or desired outcome are you hoping to achieve in your session(s)?
Is there anything you would like me to know that was not asked here?
When are you available for sessions?

MorningAfternoonEveningWeekdaysWeekends
When would you like to meet for our first session?

MonthDayYear
Date
If not a specific date tell me more about your availability
Thank you for your heartfelt and genuine responses. I honor your openness and look forward to exploring how we may work together. Once I’ve received your completed intake form, I’ll be in touch to schedule an intake call.

Sincerely,
Ann Vajradakini
Should be Empty:

Lotus Love Tantra Intake Form

Section 1: Welcome & Personal Information

Section 2: Identity and Work

Section 3: Primary Relationships

Section 4: Physical & Sexual Health

Section 5: Background & Practices

7: Life Inventory

Section 8: Intentions & Availability