Couples please note: This form is for each person. Do not email, please print and bring with you.
| Name: |
| Address: |
| Cell: _______________May I leave a voice message on this number __Yes __ No |
| May I leave a text message on this number __Yes __No |
| Email: |
| Occupation: |
| Birthday: |
| How did you find me? |
| Relationship Status: |
| Sexual Identity: |
| Present Living Situation: |
| Please let me know your satisfaction level 1-5 (5 being the best) on your overall relationship ____. |
| Please let me know your sexual satisfaction level ____. |
| How are you feeling in your heart and mind? |
| When was your last orgasm? |
| Are you seeing a therapist or psychiatrist? __Yes __No |
| Name(s)/Name of Practice: |
| Medication/Purpose/Prescribed by whom: |
| How do you feel about your body? |
| Please tell me about your diet. |
| Please tell me about your workout routine. |
| Alcohol/Drug Use? |
| Have you ever experienced trauma? |
| What childhood messages about sex/sexuality did you receive? Of those, how do they affect your sexuality today? |
| Do you have any concerns about your sexuality right now (feelings about sexual performance, your relationship, your body, self-pleasuring)? |
| What has been your experience when achieving orgasm? When alone? With a partner? Any difficulties? Positive experience? |
| Describe the history of your sexual relationships: (talk about the number of partners, what sexual activities you have experienced, and the issues/conflicts that have emerged from your intimate relationships). If this is a jealousy trigger, please write n/a. Call me and tell me over the phone. |
| Describe your present sexual interactions, such as intercourse or self-pleasure, your present pattern, how often, your current partners, etc. If this is a jealousy trigger, please write n/a. Call me and tell me over the phone. |
| How often do you think about or desire sex? |
| What are your long-term sexual goals? |
| What are your top three primary goals from our work together? |
| What is the main reason you reached out for coaching? |
| Please tell me something you love about yourself. |
| Please tell me something that interests you or that makes you unique. |
| Write anything else that you think would be important for me to know or that you just want to tell me. |