Coaching Intake Form

Feel free to answer these questions in as much detail as you choose, and skip any of them that aren’t relevant to you. If you would rather share any information with me during our Get Acquainted call, please make a note on the form so I can be sure to discuss it with you.

Name

Phone

How did you hear about me?

Challenging things from your sensual/sexual history that you want me to know are:

Wonderful things from your sensual/sexual history that you want me to know are:

Challenging things about your current sexuality that you want me to know are:

Wonderful things about your current sexuality that you want me to know are:

Please list any medical conditions that affect your sexuality:

What would you like to tell me about your current intimate relationship/s?

If you have a partner, do they know that we will be working together? Would you be interested in having them join you for some of the sessions?

Please tell me about any previous experience with sex therapy and/or sexual bodywork (such as sexological bodywork, sensual massage, sex work, surrogate, tantra, etc.). If you are currently working with a therapist, do they know that you are interested in somatic sex coaching?

What else would you like me to know about your sexual history or current desire patterns, including gender identity, sexual orientation(s), self-pleasuring practices, fantasies, use of pornography, or any other information that you feel may be important for me to know?

Please share any experiences you've had with sexual assault or trauma that you feel might affect our work together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.

If relevant, please share any history you have of pregnancy, labor and delivery, miscarriage, or abortion that you feel might affect our working together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.

How would you like to feel at the end of our work together?

What questions do you have for me? What would you like to know about sex coaching, my experience and background, or anything else that might affect our work together?

Many thanks to Caffyn Jesse and Liam Snowdon for guidance in making this form.