Client Intake Form Name* First Last Location* Email* Enter Email Confirm Email Occupation:* Passions and Interests:Are you single? Married? Divorced? Dating?Do you have any medical conditions I should know of?Are you on any medications? Which ones?Are you now or have you in the past been treated for mental issues?Are you on any medications for these issues? If so, what?Have you gone thru any addiction? And did you receive professional support for it?Please describe your wellness journey so far, what have you explored to support your deepest wellness for mind, body and soul?Do you have a regular spiritual or mindfulness practice?How do you feel about your body? Have you had body image challenges ever in your life?How satisfied are you with your sex and intimacy life?What transformations in your sex life, if any, would you like these sessions to support?How important to you on a scale of 1-10 (10 being the highest) is it for your to create this transformation?Have you experienced sexual abuse or trauma?If yes, have you received therapy or support for this?Is this something that you would like support for in the session?What was your most amazing sexual experience? What made it so amazing?What is your relationship to pleasure? Pleasure can be sexual but also includes pleasures, like hobbies, people we love, trips, activities, pets anything that brings a sense of ease, fulfillment or joy.How often do you engage in these things, how much do you prioritize them? Why?Are there any relationships from the past that feel unfinished or needing closure? Is that an issue you would like to work on in our session?Are you wanting to attract a partner?If so, what have you explored thus far, to attract one?Is that something you would like to work on in our sessions?Have you done tantric work, women’s work or somatic healing before? Please describe to your comfort.What is your relationship to your emotions? Do you feel comfortable expressing emotions? Do you easily laugh or cry, in front of others? or do you feel more private with your emotions? How has the emotional life been in your relationships?If you could choose 3 words to describe what you want to create thru a session with me, what would they be?Imagine you are the Queen of Womanly Embodiment, living at your personal deepest potential as a Woman…What do you wear? How do you move? What do you do with your time? Who is around you? How do you talk? Describe anything that tickles your imagination as you envision yourself as this.Anything else you would like to share with me, that you feel like sharing or that you feel is important for me to know?Anything else you would like to share with me, that you feel like sharing or that you feel is important for me to know?Client Statement Of Responsibility And Liability Waiver Sometimes strong emotions memories or sensations arise and it is up to me (the client) to decide if I want to pause or stop or if i want to work through them and release them. by scheduling session to take full responsibility for my choices and release the practitioner from any liability regarding anything related to the session ,physically, emotionally or mentally. I agree to tell the session giver immediately and clearly if i’m experiencing pain, discomfort or want a pause or stop the session. I understand that the intention of this session is to bring about a profound integration of sexuality and spirituality, supporting a clear flow of chi through my body and a sense of oneness all that I am. SignatureDate MM slash DD slash YYYY Thank you ! Blessings for a wonderful session and/or series of sessions Δ
