Teen Program Intake Form
12 week virtual program for teens! Please note: Julia is the only person who will see this form
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Email *
1. Name & Pronouns *
2. May I use your email to contact you between sessions if necessary? *
3. Other methods of communication you are comfortable with. e.g. Instagram @askauntiejulia
4. What is your gender? (female, non-binary, male, other - please describe) *
5. If partnered, what are their genders? (Female, non-binary, male, other - please describe)
6a. Tell me a little about your relationship with sex.   I'm interested in knowing where we're starting from. Are you currently sexually involved with someone? If so, is it satisfying?  What is your relationship structure? *
6b. If you're not in a relationship, do you have play partners? Is it satisfying?
6c. What does 'safer' sex mean to you?   *
7a. Tell me a little about your relationship with yourself. When you're feeling amazing, how do you talk to yourself? *
7b. When you're feeling down/dismayed, how do you talk to yourself? *
7c. What do you really love about yourself? *
7d. What do you want to change about yourself? Or, what could we work on to help you reach some of your goals? *
8a. Tell me a little about your relationship history. What are some important lessons you have learned from relationships? I will send a relationship history worksheet if you'd like some help with this. *
8b. What are your big values in a relationship? If you don't have an answer, we will work on this. *
9. Have you worked with a coach before? *
10.  On a scale of 1-10 (10 is the highest), how comfortable are you talking to your parent/guardian about sex? *
11. On a scale of 1-10 (10 is the highest), how comfortable are you talking to your parent/guardian about romantic relationships? *
12. On a scale of 1-10 (10 is the highest), how comfortable are you talking to your parent/guardian about platonic relationships aka friendships? *
13. What is important for me to know, and NOT share with your parent/guardian? For example, if you want us to use a name and pronouns in group that are different from what you want me to use with your parent/guardian, or you're dating someone and you don't want your parents/guardians to know *
14. What are you most interested in learning more about/talking about in regards to sex and relationships? *
15. What do you feel like is adequately covered in school or at home in regards to sex and relationships, so you don't want to know anything more about it? *
16. What do you feel needs to be covered MORE at school or at home in regards to sex and relationships? *
17. How did you learn where babies come from, and at what age? *
18. Describe the culture in your home around confronting hard truths e.g. my viewpoint is different from yours, what do we do about that? *
19. Do you ascribe to a particular faith? If so, which one? *
20. There may come a time when I need to contact your parent/guardian about something you have shared in our group. I will inform you before I contact them. (If you choose no, you will not be accepted into this program) *
21. There may come a time when I need to contact the authorities if you share that you or someone you know has been harmed or will be. I will let you know before I contact the appropriate authorities. This is Julia's duty to report. (If you choose no, you will not be accepted into this program) *
Thanks for taking the time to fill this out thoughtfully. Julia will send you further information once your parent/guardian completes their intake form and you have been selected to participate. I am thoughtful about the groups I put together in regards to dynamics and will create groups based on maturity and interests.
Feel free to email me: julia@juliasheldon.com if there are questions that don't get answered in the follow-up email.
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