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Sessions
About
Pricing
Events
Testimonials
Wild Eros
Blog
Media
Resources
Booking
Intake Form
Name
*
First Name
Last Name
Pronoun(s):
Email Address
*
Date of Birth
MM
DD
YYYY
Phone
(###)
###
####
Referral source:
Intention(s) and Goals: Your intention(s) and goals will guide this work. I am here to support your deepest and highest intention(s) for yourself. Please consider and state your deepest intention(s) regarding sexuality, eros, spirituality and wellbeing. In addition, please write down any specific goals that you would like to accomplish during our work together:
*
1. Difficult things from my sexual/sensual history I want you to know are:
2. Wonderful things from my sexual/sensual history I want you to know are:
3. Difficult things about my current sexuality/sensuality I want you to know are:
4. Wonderful things about my current sexuality/sensuality I want you to know are:
5. On a scale of 0-10, how well do you accept your body as it is? (0 = No acceptance 5 = Moderately accepting 10 = I love and accept my body exactly as it is.) Add details about your body image:
6. Please describe the sexual education and messages you received about sexuality while growing up:
7. Please describe your first sexual experience/s, and how you feel those experiences affected you:
8. Please describe a peak erotic experience. Think of your best erotic experiences. (What was happening? What was your inner experience? Was it alone or with a partner? What were you sensing? What were you thinking?):
9. Tell me about your intimate relationship/s:
10. Do you have scars that concern you? (Scars from abdominal surgery, trauma, childbirth, circumcision and other causes can impact sexual function. Scar tissue remediation is a modality of sexological bodywork.) If yes, please describe the scar and when it occurred:
11. Tell me about previous sex therapy and/or erotic bodywork experience (sexological bodywork, sensual massage, sex worker, surrogate, tantrika, other) What was most helpful? What was least helpful?
12. Do you have a spiritual practice or a sense of the sacred that is part of your life? What is the role of sexuality within this (if any)?
13. Please add anything else you would 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 relevant:
Do you have any of the following?
Pregnant
No
Yes
Inflammation
No
Yes
Heart Condition
No
Yes
Arthritis
No
Yes
Diabetes
No
Yes
Vein or Artery Condition
No
Yes
Breathing Problems
No
Yes
Pain
No
Yes
Epilepsy
No
Yes
Recent Surgery
No
Yes
Allergies
No
Yes
Genital Pain
No
Yes
Skin Condition
No
Yes
Communicable STI
No
Yes
Are you taking any medication or substances that could block pain or relax your muscles?
Are you currently suffering from any physical or emotional symptoms related to traumatic experience? If YES, please explain:
Do you have any sexual history, physical or mental illness, or other conditions that may affect your response to a bodywork session? If YES, please explain:
Informed Consent and Waiver
Somatic Sex Education is not psychotherapy or medical treatment. I understand that it is recommended to have additional avenues of support, such as a psychotherapist, when pursuing deep inner work.
I understand
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 understand
I have stated all medical conditions that I am aware of, and I will update Monica on any changes in my health status:
I agree
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:
I understand
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.
I understand
Appropriate hygiene protocols will be used, including gloves for all genital touch.
I understand
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.
I understand
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.
I understand
Cancellation Policy
48 hours notice is required for cancellation or rescheduling
Sessions cancelled or rescheduled between 24 to 48 hours will be charged half the session amount.
I understand
Sessions cancelled or rescheduled with less than 24 hours notice, or no shows, will be charged the full session amount.
I understand
Waiver
I have read, understand and agree to the above statements. By signing this release, I hereby waive Monica and The Inner Arts Collective of any and all liability, past, present or future, relating to Somatic Sex Education and Bodywork. Please type full name and date below:
Thank you!