Tantra Massage Application Form:
100% Confidential, Personal and Discrete
Your Full Name
*
First Name
Last Name
Your Residence (City)
Mobile Phone Number
*
-
Area Code
Phone Number
E-mail
*
How would you like to get contacted?
Email
Cell call
Text
WhatsApp
Other
Gender
Female
Male
Age Range
Under 30
30-39
40-49
50-60
Over 60
Please choose the session you wish to attend
One Day Retreat incl. one 2.5hr Tantra Massage for Women provided by Dirk
Weekend Retreat (3 Nights) incl two Tantra Massages each 2.5hrs for Women provided by Dirk
Tantra Massage 2.5hrs for Women provided by Dirk
Preferred date and time for your session (I will do the best to accommodate your preference)
-
Month
-
Day
Year
Date
Preferred time for your Tantra massage
Mornings
Noon
Afternoon
Evenings
What would help you feel most comfortable and at ease during a session?
Is there anything you would like me to be aware of to better support your experience?
In what level are you (the most) interested in Tantra?
Physical
Emotional
Spiritual
All of them
None
Which of the following resonate with you right now?
Feeling mentally or/ and emotionally overwhelmed
Disconnected from my body or sense of self
Seeking deeper relaxation beyond traditional wellness
Looking to reconnect with my feminine energy
Navigating changes in a relationship or persinal life
Simply wanting to feel more alive and present
Do you have any serious medical condition that needs consideration (incl. STI) ?
Yes
No
If yes, please explain:
You have read the information provided on the website and you accept that this is not a sexual service.
Yes
No
Please tell me more about what you need and what you are searching for. Be as honest as you can be and describe with your own words so that I can plan the best possible experience for you.
Thank you for your application. If it feels like the right fit, you will be invited to a brief, private consultation to ensure the experience is fully aligned with your needs and expectations. All communication is handled with complete discretion.
Submit
Should be Empty: