Intake Form

 

Name *
Name
Date of Birth
Date of Birth
Phone
Phone
Please select desired length of time for your first session
Do you have any of the following?
Informed Consent and Waiver
Somatic Sex Education is not psychotherapy or medical treatment:
I understand that any touch will be given only at my request and solely for my own benefit, education and pleasure. I agree to communicate my needs as they arise, including stopping any exercise at any moment, should it become uncomfortable for me:
I have stated all medical conditions that I am aware of, and I will update Monica on any changes in my health status:
Monica does not act as a surrogate partner. She remains fully clothed during sessions. She will not become romantically or sexually involved with a client. Professional conduct is expected at all times within the container of the client-practitioner relationship. I understand that these sessions are about me, my own internal experience, and intended to deepen my relationship with myself:
All touch involved is one-way only, from practitioner to client. Professional conduct is expected at all times, including verbal respect for the professional client-practitioner boundary. Any deliberate violation of these boundaries will result in termination of session without refund.
Appropriate hygiene protocols will be used, including gloves for all genital touch.
Drugs and alcohol are not compatible with somatic sex education. Any client arriving to a session under the influence of drugs or alcohol will be sent home.
In certain cases, the complexity of client concerns may be outside the scope of Somatic Sex Education. I understand that Monica may recommend other modalities (such as psychotherapy) alongside OR instead of Somatic Sex Education. Monica reserves the right to terminate sessions with those clients whose needs are outside of her scope of practice.
Cancellation Policy: 24 hours notice for cancellations is required. A $40 cancellation fee applies to sessions cancelled less than 24hours in advance. For prepaid sessions, failure to show up for the session will result in loss of that session. Emergencies are exceptions.
Waiver