Somatic Sex Education Intake Form

Required Field

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Contact Info

Mobile Phone

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Your background

Please share with me any aspects of your identity that are important to you, such as race, ethnicity, class, physical ability, gender, sexuality, religion/ spirituality, etc.

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How do you spend your time (work, hobbies, etc)?

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What are the challenges or issues you would like to address with Somatic Sex Education (SSE)?

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Do you have specific goals that you would like to reach?

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What is appealing to you about SSE?

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What has prompted you to seek out SSE at this particular moment in your life?

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What (if any) fears do you have about starting SSE?

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Are you currently partnered? If so, have your present concerns impacted your relationship(s)?

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When life gets tough, do you have specific people, pets, groups, or practices that you can lean on for support? If so, please describe some of them and how they help you.

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What are some aspects of your erotic self that you love? (If you can't think of any, that's ok!)

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How did you first hear about Somatic Sex Education?

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Is there anything else you would like me to know about you?

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Thank you for filling out my Somatic Sex Education intake form! You will receive an email confirmation shortly, with a link to schedule your first appointment.

If you have any questions, please email me at rachelyukimura@protonmail.com.

Thank you and I look forward to working with you!