Intake Coaching Questionnaire

1
Full Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number* This field is required.
4
E-mail* This field is required.
5
Occupation* This field is required.
6
Employer* This field is required.
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Gender Orientation* This field is required.Select the one that feels truly YOU!
Cis-Female
Cis-Male
Non Binary
MTF
FTM
Intersex
Gender-Fluid
9
Marital Status* This field is required.
Single
Dating
Engaged
Married
10
Children?
11
As your coach it is important for me to understand how you view the world in general

and yourself in particular.

Every person has their own unique and personal way of interacting with their surroundings.

These questions will hopefully provide a means for me to understand you and your

current position more closely and thus enable me to coach you to bring out your best.

Please take some time to answer these questions as thoughtfully and clearly as

possible. These questions are designed to be “mulled over” and to stimulate your

thinking on items that may in the past been automatic in the past.

If you have any queries please let me know and we can discuss them.
12
How does your current lifestyle, contribute to achieving your intimacy goals?* This field is required.
13
If you could change some aspects of your situation what would you choose to change?* This field is required.
14
What do you consider to be your greatest accomplishment(s) so far?* This field is required.
15
What activities have meaning and heart for you?* This field is required.
16
How do you find you are best motivated? Internally? Externally? Both?* This field is required.
17
What do you believe to be your most important values? Do you believe you are living congruently with these values?* This field is required.
18
How do you respond when you are in a really challenging situation?* This field is required.
19
What are your intentions for seeking this work at this time?* This field is required.
20
What do you hope to gain from this experience?* This field is required.
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Are you currently in a romantic relationship?* This field is required.
YESNO
22
What's Your Relationship Structure?* This field is required.
Monogamous
Polyamours
Open
Swingers
Monog-mish
Solo-Poly
23
Are you currently working through challenges or concerns in that relationship?* This field is required.
YESNO
24
Please tell me more about the challenges you are facing.
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Please briefly describe past romantic relationships and any patterns you’ve noticed.* This field is required.
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Are you currently in an ongoing sexual relationship?* This field is required.
YESNO
27
Describe your current emotional and mental state.* This field is required.
28
Describe your current physical and body state.* This field is required.
29
Do you have any mental health conditions (diagnosed or undiagnosed) you feel are relevant to share?* This field is required.
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Do you experience or have you experienced addiction of any kind?* This field is required.(Alcohol, nicotine, marijuana, gambling, pornography, sex, etc.)
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Describe any physical, emotional, or verbal abuse you have experienced. Please include age(s), if applicable.* This field is required.
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Have you experienced sexual trauma?* This field is required.
YESNO
33
Please Describe include age(s), if applicable.* This field is required.
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Do you experience fear, anger, or resentment toward any gender?* This field is required.
YESNO
35
If "YES" Please Describe
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Do you experience abandonment issues or have a history of abandonment?* This field is required.
YESNO
37
Please describe.
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List any significant fears or phobias.* This field is required.
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Have you ever had a near-death experience?* This field is required.
YESNO
40
If Yes Please Describe
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Please describe any religious conditioning you received regarding sexuality.* This field is required.
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Please describe any cultural, societal, familial, or ethnic conditioning you received regarding sexuality.* This field is required.
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43
Please describe any resistance you have had—or currently have—around receiving pleasure.* This field is required.
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What brings you pleasure in your body (sensual or sexual)?* This field is required.
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What is your relationship with your body overall?* This field is required.
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What is your relationship with your genitals?* This field is required.
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Do you experience numbness, pain, or discomfort in your genitals?* This field is required.If "YES" Please Describe
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48
Do you experience extreme sensitivity in any areas of the body (genitals, nipples, breasts, etc.)?* This field is required.
YESNO
49
Do you experience difficulty or inability experiencing orgasm?* This field is required.If "YES" Please Describe
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50
Are you ticklish or averse to light touch?* This field is required.
YESNO
51
Are you sensitive or averse to firm pressure or deep touch?* This field is required.
YESNO
52
When was your most recent sexual health examination (month/year), and what were the results?* This field is required.
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Have you ever tested positive for a sexually transmitted infection or disease? * This field is required.If "YES" Please Specify
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Do you have HIV/AIDS or any other life-threatening illness?* This field is required.
YESNO
55
Please list any current or past medical conditions or illnesses you feel are relevant.* This field is required.
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Do you have any sensory impairments (vision, hearing, touch, etc.)?If "Yes" please describe
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Do you have any hernias or abdominal conditions that could create risk with abdominal work or touch?* This field is required.
YESNO
58
Have you ever had cancer of any type?* This field is required.Please describe
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Are you experiencing any hormonal imbalances?* This field is required.Please Describe
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Please list all medications you are currently taking (prescription, OTC, herbal, or plant medicines).* This field is required.
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61
Date of last menstruation (if applicable):
Date
Year
Month
Day
62
Do you experience issues related to menstruation, perimenopause, or menopause?* This field is required.Please Explain
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63
Have you ever been pregnant, had a miscarriage, or an abortion?* This field is required.If so please provide Ages, & brief context.
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64
Have you given birth?* This field is required.If Yes, I'd love to hear your Birth story below.
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Are you currently pregnant or possibly pregnant?* This field is required.
YESNO
66
Do you experience any of the following? * This field is required.Select all that apply
Erectile dysfunction
Delayed ejaculation
Premature ejaculation
Impotence
None
67
Do you have or have you had an addiction to pornography?* This field is required.
YESNO
68
How often do you masturbate to ejaculation?* This field is required.
Daily
Weekly
Monthly
Raely
Prefer not to answer
Never
69
Have you had any surgeries involving sexual or reproductive organs?* This field is required.Please Describe
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Have you had breast surgery (mastectomy, augmentation, reduction, "Top Surgery" etc.)?* This field is required.
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Have you had any other significant surgeries?
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Is there anything else you feel is important for me to know at this time?
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I understand and agree that The Intimate Way is a professional, non-sexual, consent-based somatic coaching practice, and that no sexual services, erotic touch, or sexual performance are offered or provided.* This field is required.Please note Completion of this intake requires agreement with the statement above. If this box is left unchecked, your submission will not be reviewed and you will be automatically disqualified from receiving services through The Intimate Way. Once submitted: Your intake will be reviewed for alignment, safety, and readiness If this work feels like a good mutual fit, you will receive an email with next steps, including a booking link for a discovery call Before submitting, take a moment to pause, breathe, and notice how your body feels. You may continue when ready.
Yes, I understand!
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