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Intake Questionnaire

Thank you for your interest in my work. Please answer the following questions if you are interested in scheduling a session or having a free 15 minute phone consultation. This helps me to know more about how I might help you, and it helps me understand where I need to follow up to make sure we are in alignment. It can also serve to help you prepare for our work together. If you are coming in as a couple, please fill out questionnaires as individuals.

  1. Please describe why you are attracted to working with me.
  2. What issue/s would you like my support in assisting?
  3. How will your life be different when these issues are resolved?
  4. What has blocked you from experiencing this before now?
  5. What are your expectations about our session?
  6. Do you have experience with Tantra, meditation, breathwork, massage, dance, yoga, martial arts, Non-violent communication, NLP, Reiki, or any other personal growth or energy work? If so, please tell me a little bit about that experience...
  7. Describe your relationship with your body…
  8. Describe your relationship with your emotions…
  9. Describe your relationship to spirituality (do you believe in God or some higher power, do you have a religious background, do you have a spiritual practice)?
  10. Are you currently single, dating, in partnership, married, or other?
  11. If you are in an intimate relationship does your partner know you are seeking intimacy integration work?
  12. Are you willing to feel uncomfortable to experience your vision for yourself?
  13. Are you willing to do home assignments and exercises to experience your vision?
  14. Is there anything else you think I should know about you?
  15. What is your name?  (required)
  16. What is your e-mail address?  (required)
  17. What is your phone number? 
  18. Is it ok to call?
If you are human, please leave this blank: