Tantra Session Intake Form

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It is an honor and a privilege to embark on this journey with you! To help you gain clarity about your desires and for me to be able to guide you as smoothly as possible, please complete the following short survey. It also helps us meet up sooner! If you need to contact me directly please email me at solecosmiclove@gmail.com

Name *

Website/Facebook/LinkedIn/web article about you

Email *

Address - city/suburb at least

Preferred 3 dates/times for our first session *

Phone number *

Current Relationship Status (If in a relationship/married for how long?)

$100 booking deposit method *

https://revolut.me/marias21l4

Personal website/Linkedin/social media pages *

General Questions

Why do you want to work with me? *

What do you want to achieve in working with me? *

The following questions have to do with your current sexuality please answer as honestly as possible.

Have you ever seen a tantra practitioner before? If yes who and when

How often do you self pleasure (over the last 6 months)

Never

Occasionally (Once a month)

Sometimes (Once a week)

Often (Once a week or more)

Every day or nearly every day

How often have you had sexual intercourse in the last year?

Never/Less than 2 times

Rarely (less than once a month)

Sometimes (once or twice a month)

Often (Once to three times per week)

Frequently (5 or more days per week)

Are you experiencing any of the following physical manifestations?

Erectile dysfunction/loosing erection

Premature ejaculation/wanting to last longer

Feeling overly sexual/obsessive

Porn attachment/addiction

Emotional trauma

Lack of libido

Desire to learn and grow!

Loss of interest in sex

Other:

If you marked “Other” above, what is it?

My current feeling of sexiness is

Not sexy at all

Super Sexy

Clear selection

My current feeling of self love is

Not loving at all

Super Loving

Clear selection

My current level of satisfaction with my sex life is

Not satisfied at all

Super Satisfied

Clear selection

My current level of satisfaction with my love/romantic life is

Not satisfied at all

Super Satisfied

Clear selection

My current level of feeling on purpose in my life is

Not aligned

Super Aligned

Clear selection

My current level of feeling turned on is

None

Super turned on

Clear selection

My knowledge of chakras/energy is

None

Expert

Clear selection

My experience with tantric breath work/exercises is

None

Expert

Clear selection

The following questions have to do with mental health please answer as honestly as possible:

Have you ever been diagnosed with mental illness? If so what and when *

Are you currently taking or using any prescription or recreational drugs? If yes what, how much and how often? (All answers are kept strictly confidential and are for my own knowledge only to tailor coaching). *

Thank you for completing these questions! I look forward to working with you!

Is there anything else you would like me to know?

By signing your name below, you agree to be coached, you take 100% responsibility for your satisfaction and experience in this and all future sessions, and that you release the provider and coach from any liability for any possible legal matter you would wish to pursue at any point in the future. *

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