1:1 Mentorship
This form is the first step in our work together. It helps me understand your individual needs and relational dynamics through a spiritual somatic lens. Our process draws on neuroscience-based tools to support co-regulation, emotional resilience, esoteric wisdom, and embodied connection.
Full Name
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Gender
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Pronouns
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Email
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example@example.com
Phone Number
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Format: (000) 000-0000.
Address
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Street Address
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Date of Birth
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Day
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Date
How did you hear about Marissa Rose?
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In person Events
Social Media
Word of Mouth
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What drew you to wanting to work with me? Please let me know what is going on in your life that brought you to this application.
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What do you desire to work on together? Select as many as resonate.
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Conscious Menstruation
Masculine/Feminine Union (Tantra)
Sacred sexuality
Somatic Sex Education
Sexological Bodywork
Pleasure/Intimacy Coaching
Romantic Partnership
Embodiment
Spirituality
Quantum Shifts
Tell me a little about yourself. What are you interests and hobbies? Do you have a partner, kids and pets? How is your social life? What LIGHTS you up?
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What is your intention for your growth in this container?
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What religious or spiritual beliefs do you hold? Please describe any beliefs around marriage and sexuality that are influenced by your religion, and you currently hold. For example: Sex before marriage is a sin, or sex is a pathway to divinity. There is no wrong answer.
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Have you done womb work, conscious menstruation, or been part of any Red Tents? Please explain if so.
How much time do you devote to your self-care? This could include exercise, meal prep, self-pleasure, reading, writing, nutrition, etc. Please be specific in what you're doing for your physical body.
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What is your relationship to self pleasure?
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What is your relationship to pleasure in partnership?
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On a scale from 1-10, how much stress do you have due to work?
On a scale from 1-10, how much stress do you have due to family?
On a scale from 1-10, how much stress do you have due to romantic relationships?
On a scale from 1-10, how much stress do you have due to friendships?
Please select your relationship style.
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Monogamous
Polyamorous
Non-monogamous
Somewhere in between
Still discovering
Are you a relationship(s)?
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No, single
Yes, partnered
Yes, multiple partners
Have you ever experienced sexological bodywork, tantric bodywork, or worked with a somatic sex educator?
How much time per week can you dedicate to integrating what you learn from our sessions?
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What is the timeline of container you would like to work in?
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Please Select
3 months
6 months
9 months
12 months
Custom timeline
Please share anything you feel is important for me to know as we consider working together. This might include emotional triggers, personal or relational boundaries, past experiences with therapy or healing work, or any sensitivities—physical, emotional, or energetic—that could support a more attuned and safe container for you. You’re also welcome to share anything that helps me better understand how to best support you in this process.
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Somatic Sexology & Priestess Temple Arts
The following questions are only applicable if you desire to work with me for somatic sex education, Priestess Temple Arts (Sacred sexuality), Tantra, and/or sexological bodywork. If this is not your intention, please scroll down to "Legal Disclaimer" and skip this portion. All questions here are *optional*, so if anything feels unsafe to answer, please skip.
Briefly describe your attitudes, thoughts, feelings, or perceptions about your body, about self pleasure, and about orgasm.
Briefly describe your attitudes, thoughts, feelings, or perceptions about: oral sex, anal sex, and penetrative sex.
Please describe the sex education and messages you received about sexuality when you were growing up.
Please describe your current understanding of sex in relation to spirituality.
If you are in a relationship, what do you find most difficult in connecting intimately?
If you are comfortable, please share your peak sexual experience.
If you are comfortable, please share any difficult sexual experience(s) that may relate to work we are doing. You do not have to go into detail here if it is triggering, it can be high-level.
Please share your erotic fantasies if they relate to the work we may do together and what you emotional connection is to fantasy. Is it exciting? Is it scary?
If you are troubled by any erotic fantasies, please describe if you are hoping to change this.
Please share what you would like to explore in this container.
Do you have any medical conditions?
Yes
No
If so, please describe.
Tell me about your experience with therapy, coaching or bodywork, if any:
Please add anything else you think is important for me to know.
Legal Disclaimer
While Marissa Heeter has training and experience in all of the services that she provides, she is not a licensed health care professional. Therefore, Marissa Heeter (Marissa Rose) cannot be relied upon to properly treat, diagnose, or advise any of her clients or participants. The services provided through Marissa Heeter are offered with the view that each individual is ultimately responsible for their own decisions, actions, and behaviors. Services provided by Marissa Heeter are not intended to be a substitute for professional mental health or medical advice, diagnosis, or treatment. I understand that any activities I participate in are voluntary. Any risk of engaging in activities including, but not limited to, breath work, hands-on bodywork, dance, massage, Priestess Temple Arts, and/or yoga is undertaken with my full willingness. I understand that every practice suggested by Marissa Heeter is not a requirement, and I may choose not to engage in any of the activities offered. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding health conditions. In no event shall Marissa Heeter be held liable for any direct, indirect, incidental, consequential, or punitive damages resulting from engagement with any of her services. In no event shall Marissa Heeter be held liable for any direct, indirect, major, or minor physical, mental, or emotional injuries that occur on her property.
By selecting below and signing at the bottom, I agree to have read the Legal Disclaimer Above, in it fullness and entirety.
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