Date of Birth
Date of Birth
Intentions 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. *
Sexual History and Information: (Please address only those questions that feel relevant. I assure professional confidentiality. If you want me to work together with your psychotherapist, medical doctor or other health practitioner, I will ask you to sign a release form.)
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.
Bodywork: Somatic Sex Educators who are Sexological Bodyworkers are trained to do genital and anal touch, at the request of the student, and when deemed appropriate by the practitioner. Through this touch, we assist students in developing presence within the body, opening interior awareness, and learning how the body can become more and more alive. We offer experiential learning opportunities that consciously access profound ecstatic and erotic states. While direct bodywork is not possible over Skype, sessions can be tailored to guide students through their own self-exploration while being witnessed/observed by the educator. If you would like to include bodywork as part of your learning experience, please complete this section of the intake form:
Do you have any of the following conditions?
Are you currently suffering from any medical condition that impacts your sexual function? If yes, please specify.
Are you currently suffering from any physical or emotional symptoms related to traumatic experience? If YES, please explain:
INFORMED CONSENT AND WAIVER Please read carefully. By checking each box, you are acknowledging and agreeing to these terms.
I have read, understand and agree to the above statements. Please type full name and date below: