Intake Form
Please take your time to fill out this form before we get to meet, and share with me anything you’d like me to know about you. If any of these questions feel too overwhelming, feel free to leave them blank and we can discuss them in person instead.
Name
First Name
Last Name
Pronouns
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referral Source
Intentions/ Goals
1. Difficult things from my sexual/sensual history I want you to know are:
2. Wonderful things from my sexual/sensual history I want you to know are:
3. Difficult things about my current sexuality/sensuality I want you to know are:
4. Wonderful things about my current sexuality/sensuality I want you to know are:
5. On a scale of 0-10, how well do you accept your body as it is?0 = No acceptance 5 = Moderately accepting 10 = I love and accept my body exactly as it is. Add details about your body image
6. Please describe the sexual education and messages you received about sexuality while growing up:
7. Please describe your first sexual experience/s, and how you feel those experiences affected you:
8. Please describe a peak erotic experience. Think of your best erotic experiences. What was happening? What was your inner experience? Was it alone or with a partner? What were you sensing? What were you thinking?
9. Tell me about your intimate relationship/s:
Do you have scars that concern you? (Scars from abdominal surgery, trauma, childbirth, circumcision and other causes can impact sexual function. Scar tissue remediation is a modality of sexological bodywork.) If yes, please describe the scar and when it occurred:
Are you currently suffering from any physical or emotional symptoms related to traumatic experience? If YES, please explain:
Do you have any sexual history, physical or mental illness, or other conditions that may affect your response to sex coaching, sexological bodywork, or brainspotting therapy? If YES, please explain:
Submit
Should be Empty: