Peace+Pleasure+Passion Participant Questionnaire
This confidential questionnaire will help us to talk with you about your goals for participating in the program. Please answer honestly.
Email address *
I found out about this program through *
Your answer
My age is... *
Your answer
My ethnicity is/ethnicities are... *
Your answer
The phrase that most accurately describes my gender is... *
My goals/reasons for participating in the program are... *
Your answer
5 adjectives that best describe my current sex life are... *
Your answer
I am currently sexually attracted to (check all that apply) *
Required
I am currently romantically attracted to (check all that apply) *
Required
I am currently emotionally attracted to (check all that apply) *
Required
My earliest learning about sex taught me that sex is.... *
Your answer
My current relationship status is *
I am currently *
I can participate in the monthly workshops... *
Something about me that is important for you to know and relevant to my participation in the program is
Your answer
I have no physiological (physical) or psychological (emotional, mental) condition that could prevent me from participating fully or impair my participation in the program. *
I understand that in the program I will be engaging in a number of physical, emotional, or contemplative activities individually, with a partner or in a group that I may experience as challenging, intimate, sensual, or erotic. I understand that I retain my right to say no and/or not participate in any activity. *
I agree to not share any personal information of participants or facilitators that is shared with me during the program. *
I agree to not engage in sex or sexual contact with any participant during the program. I agree to not initiate sex or sexual contact with any staff member. I understand that staff members will not initiate sex or sexual contact with me. *
I am aware of and acknowledge that I am consciously and willingly choosing to participate in this program. I agree that I will hold blameless and not hold liable Center for Culture, Sexuality, and Spirituality and its parent company, KHPRA, Inc, its officers and agents, or its staff for consequences resulting from my participation in the program. *
I am typing my full legal name here as an electronic signature to the affirmations above. *
Your answer
A copy of your responses will be emailed to the address you provided.
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