Couples & Poly-Pod Intake Form
Questions for you to consider prior to joining me for a 20-minute introductory call. You may do this together or complete the questions individually and mail them to me separately. 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. I will not share any info with either partner that I have not been specifically given permission to share.
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Names or Pseudonyms *
Pronouns
Emails *
Okay to email? *
Phone Number(s)
Okay to email this call and/or text?
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Your intention(s) and goals will guide this work. Please consider and state your deepest intention(s)regarding sexuality, eros, spirituality and wellbeing. Your intentions might be goals, hopes, dreams, wildest fantasies. In addition, please write down 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?
Do you have a spiritual practice or a sense of the sacred that is part of your life? What is the role of sexuality within this (if any)?
Relationship and Sexual History 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.
How long have you been in your current partnership?
How would you describe your current relationship? Committed? Monogamous? Open? What are your relationship goals and ideals?
Do you both want to do sessions together or as individuals (it will be together for the Relationship by Design Program)? Bearing in mind that some personal information may come up, think about whether you feel comfortable sharing everything with your current partner.
How much time and effort are you willing or able to commit to working on your relationship and intimacy?
Do you feel you and your relationship are able to handle honest communication, which may include constructive feedback, from each other?
Difficult things from my sexual/sensual history I want you to know are:
Wonderful things from my sexual/sensual history I want you to know are:
Difficult things about my current sexuality/sensuality I want you to know are:
Wonderful things about my current 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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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.
Clear selection
Add details about your body-image.
Have you previously experienced sex therapy, sex coaching or Sexological bodywork sessions? If yes, what was most helpful? What was least helpful?
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.
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 student, 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 (All parties please initial)
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 students / 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 understand 24 hours notice for cancellations is required or I will be billed for the session. Emergencies are exceptions. *
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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