Tantra Wellness Session Intake
Please allow 45- 90 minutes to fill out this form. This is a deep dive questionnaire that helps me better get to know you, allow me to curate a customized experience for you and best understand what areas of work are needed for your ultimate growth and evolution. We will review this and I will refer back to it during our time working together. Thank you for your vulnerability and for investing
in yourself.
-Ellie
Sign in to Google to save your progress. Learn more
Email *
Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Weight/ Height: *
Email:
Phone number: *
Location (City & State): *
How did you hear about my services?, Did anyone refer you?  *
Share with me your relationship status, are you Monogamous? Polyamorous? Anything specific you’d like to highlight about your current romantic dynamic? *
Do you have any children? If yes, please list their names & ages *
What are your spiritual beliefs? (Please elaborate) *
Were you raised religious?  How do you feel about religion?  Do you have trauma around religion? *
What is your relationship like with GOD?  Do you believe you have angels around you and or spirit guides with you on this journey?  AND do you have a relationship with them, tune into them/ talk to them on a regular basis?   *
What things do you for self care, self growth and healing? *
Do you workout/ move your body on a regular basis?  How often, duration?  What type of movement? *
Do you have any daily practice that connects you daily to your mind body soul?  (Meditation, Exercise, Breathing, Yoga, Walks) *
Do you meditate on a regular basis?  Is so, how often + duration? *
Briefly describe what does your morning routine consist of? *
Do you have any spiritual gifts that you're aware of?  Please give all the details so I can better understand you.  (Do you see, hear, feel, smell) *
Are you a highly sensitive person and/or an empath?  Please explain how this affects you and show up for you *
Are you aware of your attachment style in relationships? *
Do you know about chakras?  What is your knowledge on these? (advanced- very little) *
What do you do for work? How much of your time do you devote during the week to your job and are you satisfied?  *
Do you have a sense of purpose in life?  *
If you could do anything, that would be "fulfilling and soul nourishing" what would it be? *
Do you know what inner child work is, AND have you done any of this work? --Please explain *
TRAUMA: Have you experienced past trauma in your life?  Please share with me 1-5 major events that have left a lasting impact on your life (we will be working through more of this as is comes up in session and or if you're working through something currently, we can start there) *
Have you had any sexual trauma?  If so, please give me a small idea of what it was.  (rape, abusive partner, sexual assault, verbal sexual abuse, etc) *
Have you done any work around regulating your nervous system?  Are you aware of what this is or what it looks like? (fight, flight, or freeze) *
FATHER/ FATHER FIGURE: Please explain the relationship you had with your father growing up & how it is now.  Share qualities and traits of your father, both good and bad.  Share ways they have been hurtful and helpful. *
MOTHER/ MOTHER FIGURE: Please explain the relationship you had with your mother growing up & how it is now.  Share qualities and traits of your mother, both good and bad.  Share ways they have been hurtful and helpful.
 *
PARTNER/ SPOUSE: Please explain your relationship with your partner currently?  Give me 3-5 things you're working through or wanting help on in partnerships?

If you're not in partnership, where are you with how you feel about relationships?
 *
SIBLINGS: Do you have siblings? How many?  Are you the youngest, middle, oldest?  What was your relationship with them growing up?  What is your relationship now? -- List anything significant you feel I need to know about your sibling(s) in regards to you *
Were you ever bullied at any point of your life?  When and what was it about? *
Have you ever been in a relationship that was emotionally and or physically abusive? *
Do you know why you are on this planet?  Have you found your purpose/ passion? *
Completely Lost
Yes! Absolutely
What are your passions?  *
Do you know the right next steps you need to take to achieve your dreams? *
Completely Lost
Yes! Absolutely
Do you feel abundant? *
No, not at all
Yes! Absolutely
On a scale of 1-10,  how well do you accept your body as it is?  Feel free to add details about your body image. *
Do you experience anxiety on a regular basis? *
No, not at all
Yes, absolutely!
How are you with managing your time? *
Do you feel grounded and at peace most of the time? *
No, not at all
Yes, absolutely
Have you experienced any big life transitions the last several years? *
Have you experienced a tantric massage before, and if so what was your experience? *
Do you have any injuries? *
Are there any underlying issues you would like to work on? ie: learning to last longer, expanding pleasure, erectile disfunction, etc? *
What are your goals and intentions (as they will both guide this work)?  I am here to support your deepest and highest intentions for yourself.  Please explain your intentions regarding sexuality, eros, healing and wellbeing.  *
Have you worked with a practitioner/coach/ therapist before? *
If answered yes to previous question, what was it for? *
Please add anything else you would like to share regarding your sexual history or current desires.  Including gender identity, sexual orientation, self-pleasuring practices, fantasies, use of pornography, or any other information that you feel is relevant to share. *
Please include a link to your business website, LinkedIn, Facebook, or Instagram to verify your identity.  Please understand your responsiveness will remain private and discreet.  IF YOU DO NOT LEAVE A LINK OR A REFERENCE, I WILL NOT RESPOND TO YOUR SUBMISSION.  This is for my safety and discernment. *
By checking the box below, you understand that I only meet with honest and open individuals with a genuine interest in pursuing a more soulful experience.  I ensure that any information you share, including our sessions, is sacred and therefore confidential.  

There is a 50% deposit to hold the scheduled booking after our initial video call, this is not refundable.

If there is a cancellation within 48 hours of the scheduled booking,  there is a $100 reschedule fee, and the other half of the total is owed. 

 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms