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Online Intimacy Coaching Questionnaire
Welcome.
Thank you for your interest in working together.
This form is private and confidential. It helps me understand what’s bringing you here and how I can best support you. You’re welcome to share as much or as little as feels comfortable. Honesty and self-reflection are the best way to get the most from this process.
1. Contact
What is your first name?
*
Age?
*
Sex/Gender
*
Contact
*
*
City/Time Zone
*
1. Intention
What inspired you to reach out at this time?
*
(What’s happening in your life right now that made this feel important?)
What areas would you most like support with?
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What areas would you most like support with?
A
Relationship challenges
B
Intimacy and connection
C
Communication with partners
D
Loneliness or lack of touch
E
Desire and arousal
F
Sexual confidence
G
Healing after past experiences
H
Personal growth and self-understanding
I
Other
If you'd like to expand on any of your answers above.
What are you hoping will change as a result of working together?
*
2. Relationship status
Which best describes your current situation?
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Which best describes your current situation?
A
Single
B
Dating
C
In a relationship
D
In an open/polyamorous relationship
E
Married / long-term partnership
F
It’s complicated 🙂
3. Relationship history
Which best describes your previous relationships?
*
(Select any that apply)
Which best describes your previous relationships?
A
I've had one (or more), long term loving partnerships
B
I've had one (or more) relationship with typical amounts of stress and conflict
C
My past relationships were challenging and difficult
D
I have experienced one (or more) toxic / abusive relationship
4. Experience
Have you ever worked with a coach, therapist, or intimacy professional before?
*
Have you ever worked with a coach, therapist, or intimacy professional before?
A
No
B
Yes, briefly
C
Yes, ongoing
D
Prefer not to say
If yes, what was helpful or unhelpful about that experience?
What would you like to experience during our online session?
*
What would you like to experience during our online session?
A
Someone to talk to and feel safe with
B
Feel seen, connected and valued
C
Relationship clarity & support
D
Release pent up thoughts and energy
E
Receive emotional support and guidance
F
Healing from past experiences
G
Communication/Intimacy skill building
H
Sharing erotic energy and pleasure
I
Other
5. Readiness / Timing & Booking
How soon would you like to begin?
*
How soon would you like to begin?
A
As soon as possible
B
Within the next couple of weeks
C
Within the next month or two
D
I'm just exploring for now
Do you have any preferred days or times?
*
How would you prefer we meet?
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How would you prefer we meet?
A
Zoom/Facetime video call
B
Phone call
C
Not sure yet
Is there anything else you'd like to share before we take the next step?
*
Submit
