Individual Intake Waiver
Fill in as little or as much as you want to. If completing this form is not accessible to you, please email me at taararosecoaching@gmail.com and we can discuss an alternative method. Once this is submitted, I will contact you for our 20-minute discovery call.
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Name or Pseudonym *
Pronouns
Age *
Email *
Okay to email this address? *
Phone Number
Okay to call and/or text?
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Emergency Contact *
How did you hear about my practice? *
Your intention(s) and goals will guide this work. Please consider and state your deepest intention(s)regarding sexuality, eros and wellbeing. Your intentions might be goals, hopes, dreams, wildest fantasies. In addition, please share any specific goals that you would like to accomplish during our work together. These can change as we work together. *
How is your breathing?
How would you describe your energy levels?
How is your stress level?
How do you have fun in your life?
Sexual History and Information: Please address only those questions that feel relevant. I assure professional confidentiality. If you want me to work together with your psychotherapist, medical doctor or other health practitioner, I will ask you to sign a release form.
Difficult things about my current and/or past sexual/sensual history I want you to know are:
Wonderful things about my current and/or past sexuality/sensuality I want you to know are:
On a scale of 0-10, how well do accept your body as it is? (0 = No acceptance 5 = Moderately accepting 10 = I love and accept my body exactly as it is.)
No Acceptance
I love and accept my body exactly as it is.
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Add details about your body-image.
Tell me about your intimate relationship/s.
Scars from abdominal surgery, childbirth, trauma and circumcision can affect sexual function. Do you have any scars on your body that you might want to have worked on? If yes, please describe the scar and when it occurred.
Have you previously experienced sex therapy, sex coaching or Sexological bodywork sessions? If yes, what was most helpful? What was least helpful?
Do you have any embodied experience with consent (eg. workshops/classes), and/or in containers of platonic, sensual, or erotic touch?
Please add anything else you would like me to know about your sexual history or current desire patterns, including gender identity, sexual orientation(s), self-pleasuring practices, fantasies, use of pornography, or any other information that you feel may be relevant.
How May I Serve You Best? Please check or highlight items you might want to work on:
Bodywork: As a Sexological Bodyworker, I am trained to do massage and varieties of bodywork that can include genital touch. This touch is offered only at the request of the client, and when deemed appropriate by myself as practitioner.
Do you have any of the following conditions? (Please check the box for those that apply)
Are you taking any medication that could block pain or relax your muscles?
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Are you currently suffering from any physical or emotional symptoms related to traumatic experience?
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If yes, please explain:
Do you have any sexual history, physical or mental illness, or other conditions that may affect your response to a bodywork session?
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If yes, please explain:
Informed Consent and Agreement (Please initial for each):
I understand Somatic sex education is not psychotherapy or medical treatment. I understand that it is recommended to have additional avenues of support, such as a psychotherapist, when pursuing deep inner work. *
I understand that any erotic touch will be given only at my request and solely for my own benefit, education and pleasure. I agree to guide the touch to ensure that it is always beneficial, educational and pleasurable for me. Any deliberate violation of these boundaries will result in termination of session without refund. *
I have stated all medical conditions that I am aware of, and I will update Taara on any changes in my health status. *
I understand Taara does not act as a surrogate partner. She remains clothed during sessions. She uses her hands only to touch her clients. She will never become romantically or sexually involved with a student. I understand that these sessions are about me, my own internal experience, and intended to deepen my relationship with myself. *
I understand appropriate hygienic protocols will be used, including gloves for internal genital/anal touch. *
I understand drugs and alcohol are not compatible with somatic sex education. *
I understand in certain cases, the complexity of client concerns may be outside the scope of Somatic Sex Education. I understand Taara may recommend other modalities (such as psychotherapy, pelvic floor therapist, etc.) alongside OR instead of Somatic Sex Education. Taara reserves the right to terminate sessions with those clients whose needs are outside of her scope of practice. *
Cancellation Policy: I agree to the cancellation and reschedule policy on Taaras' website: https://www.sexedforthemodernbed.com/ethics *
Waiver: I have read, understand and agree to the above statements. I acknowledge and accept all the terms outlined in this waiver. By signing this release, I hereby waive Taara Rose of any and all liability, past, present or future, relating to Somatic Sex Education and Bodywork. Please type full name and date below: *
After each session, Taara suggests that you take notes about your experience. Write about practice (what happened), states (what you felt and experienced), and distractions (distracting thoughts or impulses that took away your focus). Send a copy to Taara. This will support your integration process and provide important guidance for future sessions. Please send to: taararosecoaching@gmail.com *
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