Sacred Sensuality Intake Form:
Please take the time to read through and fill in this form. Know that you are welcome to answer all questions with as much or as little detail as you feel comfortable. This form is confidential. I look forward to meeting you and working together in support of your sacred sensuality. Please note that our work together with be fully clothed.
Email address *
Name: *
Your answer
Date of birth:
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Phone number *
Your answer
Is it okay to use this number for text in case of cancellation or for general communication purposes?
Is it okay to leave voice messages at this number?
How did you find me? *
Your answer
Health History: Please share any information about your physical, emotional, or mental health that is relevant to the work we will be doing together:
Your answer
Health History: Do you have epilepsy, seizures, serious mental health issues (i.e. having been hospitalized) or severe asthma? Please explain
Your answer
Health: Are you currently taking any medication for mental health related challenges? If yes, please share the name of the medication and how long you have been taking it.
Your answer
Health: Do you currently have any mental health diagnosis? Please explain.
Your answer
Desires and Goals: What do you most desire from our work together?
Your answer
Desires and Goals: What are you most struggling with in your life right now? Is this something you would want transformed? How?
Your answer
Sexuality and Sensuality: How would you describe your sexuality and sexual history? How would you describe your relationship to your sensuality? What, if anything, about your sexuality and sensuality would you like to see transformed?
Your answer
Do you have any fears about our work together? If so, please explain. Is there anything I can do to support you in feeling safe and comfortable?
Your answer
Personal History: What is your current living situation?
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Personal History: Are you in a relationship? If so, please describe your relationship to me.
Your answer
Personal History: Are there any significant experiences in your life as a child or adult that you would like me to know about? Please share.
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Personal History: Are there any details about your current family or family of origin that you would like to share?
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Relationship with Self: How would you describe your self care practises? What or who do you typically turn to for comfort? Who would you consider to be your support network?
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Spiritual or Religious Life: Does religion or spirituality figure into your life? If so, please explain.
Your answer
Is there anything else that you would like for me to know?
Your answer
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