Welcome to the Sacred Sexuality Coaching Intake Form
This intake form is designed to help me better understand you, your journey, and your needs.The information you share here is completely confidential and will allow me to create a safe, supportive, and personalised coaching experience for you. Please answer honestly and as fully as you feel comfortable. There are no “right” or “wrong” answers — this is simply about getting to know you, your goals, and how I can best support your growth in sexuality, intimacy, and connection.
Personal Information
Name
First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Gender/Pronouns
Relationship status
Please Select
Single
In relationship
Married
Other
Sexual Orientation (optional)
Occupation
Phone Number
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Area Code
Phone Number
Email
example@example.com
Location/time zone
Background & Experience
What brings you to sex coaching at this time?
Have you worked with a sex coach, therapist of counsellor before?
Please Select
Yes
No
If yes, please describe.
What are your main goals or challenges you would like to work on?
Relationship issues
Premature ejaculation
Erectile dysfunction
Desire/arousal issues
Body image confidence
Performance anxiety
Exploring new practices (self pleasure, edging, etc...)
Understanding woman's pleasure
Pain during penetration
Other
Sexual & Relational Wellness
How would you describe your current sexual relationship with yourself?
How would you describe your current (or past) sexual relationship with your partner(s), if applicable?
What does satisfying sex life looks like for you?
What's your dream future scenario, from us working together? Describe it as best you can.
Do you experience any pain, discomfort, or anxiety during sexual activity?
Please Select
Yes
No
If yes, please explain.
Are they any cultural, spiritual, or religious beliefs that may influence your experience of sexuality?
Please Select
Yes
No
If yes, please share if you would like.
Health & Lifestyle
Do you have any relevant medical conditions or medications that might affect your sexuality?
Stress levels
Please Select
Low
Moderate
High
Sleep pattern
Please Select
Poor
Average
Good
Exercise
Please Select
Rarely
Sometimes
Regularly
Mindfulness practices (meditation, breath work, yoga,...)
Please Select
Never
Rarely
Sometimes
Regularly
Consent & Confidentiality
I understand that sex coaching is not therapy or medical treatment and does not replace professional healthcare. Everything shared is confidential unless there is a risk of harm to myself or others. Sessions are AI recorded for note taking purposes and won't be shared with anyone.
I consent to participating in sex coaching sessions.
Signature
Date
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Day
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Month
Year
Date
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