Sacred Pelvic Healing Ritual Intake Form

Sacred Pelvic Healing Ritual is a highly intimate and is often a deeply relaxing and highly sensual experience, but is not intended to be fully sexually arousing.* 

I am not a licensed masseuse and this is not traditional pelvic therapy.

We will begin by talking in person about intentions, desires, fears & boundaries, but it's helpful to begin that process now. Please be honest with yourself and with me. Please keep in mind and heart that while this session may be outside your typical comfort zone, it is essential that you feel a sense of free will and that our session be completely consensual. 

Email *
Name *
Phone number *
Do you give permission to text?
Email *
Would you like to be added to my newsletter (if/when I create one ;-)? *

Please confirm your age:

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Required
Gender and Pronouns, please. *
Do you understand the following boundaries?
This is not a date.
This is not an intimate relationship. 
This is not a hand job.
This is not Sex.

You understand and agree that this is a service and does not mean an agreement of connection beyond this service. You agree to not send any flirtatious messages or nude photos. 

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Required
Please share your intentions for this session.
Do you have any concerns about receiving this service? 

Please list any sexual traumas or health challenges you are currently experiencing. If you would prefer to discuss this in person, please specify below.

Please share any other questions or additional information about yourself that would be helpful.

Scheduling: I mostly offer sessions on Monday evenings or during weekdays during the day. Please let me know your availability.


I understand that payments need to be made via Venmo in advance or by cash, and you need to give 24 hour notice to cancel. 

I agree and understand that by typing my name, that this electronic signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. Please type your legal name and today's date.

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