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Intake Questionnaire for Erotic Embodiment / Sacred Bodywork/ Tantric Massage
A divine sexuality healing session and/or tantric massage & bodywork affects all systems in the physical, emotional, mental & spiritual body. Your response to the following questions will help me create a session specific for you and your needs. All information that you provide is kept confidential.
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Your name:
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Your answer
Your e-mail address:
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Your answer
What is your intention for this session? Why with me? What do you long to get out of this? Please explain as specific as possible:
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Your answer
What feels most challenging regarding your relationship with your sexuality, your sensual essence, your body's wisdom, intuition, your soul purpose/spiritual intelligence?
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Your answer
Have you ever had a professional sexual healing or bodywork/massage session, and/or tantric session? if yes, please explain your experience:
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Your answer
What are your experiences with altered states of consciousness?
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Your answer
Please let me know if you suffer from any physical, medical, trauma or mental health condition you feel I should know about, including any medication you are currently taking:
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Your answer
Have you suffered any adverse childhood experiences? E.g. loss of a parent or sibling/close family member, conflict, difficult divorce situation, sexual, mental or emotional abuse, violence, bullying, disease, ... If yes, please explain:
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Your answer
Have you ever experienced traumatic or unpleasant sexual experiences or unwanted touch?
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Your answer
Are there any places on your body where you don't want to receive touch? If yes, please explain:
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Your answer
Is your skin sensitive and/or allergic to any oils, creams or certain fabrics? E.g. coconut oil, olive oil, almond oil, shea butter, ... If yes, please explain:
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Your answer
Do you have a difficult time lying on your back, front, or turning to your side? If yes, please explain:
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Your answer
Female-bodied people: are you pregnant? If yes, what week? Have you had any complications or have you been told you have a high-risk pregnancy?
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Your answer
On a scale from 1-10, 1=lowest, 10=highest, rate your levels of average Stress:
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very low stress
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very high stress
On a scale from 1-10, 1=lowest, 10=highest, rate your levels of average Pain:
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very low pain
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very high pain
On a scale from 1-10, 1=lowest, 10=highest, rate your levels of average Energy:
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very low energy
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very high energy
If you have had a bodywork or tantra massage before, what was your favorite part of the session?
Your answer
What else do you feel I should I know about ?
Your answer
In Tantra Massage/Bodywork, your genitals will probably be touched (with your permission). But this is not just a genital massage! Nor is it a full-body erotic massage with a “happy ending.” (Although most people feel very happy at the end!) This is a private session in which you are taken on a journey to your most inner intimate self. The entire session is held in a sacred, safe space in which you feel relaxed, comfortable, and free to express yourself.I will introduce the session and prepare our time with a guided meditation. You will be asked to set your intentions and declare your purpose for the session as part of its ceremonial beginnings – a powerful phase during which you are freeing and clearing yourself of negative interference and aligning yourself with the creative process at hand.
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I understand and agree
To prepare for the session as best as possible, I invite you to: 1. Take note of your thoughts, bodily sensations, emotions, dreams before the session. Feel free to journal or share with me beforehand 2. In case of skin sensitivity/allergy, take your own oil and/or towel with you 3. Shower right before the session (make sure the erogenous zones are fully clean externally & internally)
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I understand and agree
I understand that the session I receive is provided for the basic purpose of sexual healing and relaxation/relief of stuck energy & blockages in the physical, emotional, mental & spiritual bodies. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.
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I understand and agree
I understand that this is not an erotic service and I also understand that any illicit or sexually suggestive remarks or advances made will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
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I understand and agree
I understand that this session should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I affirm that I have stated all my known medical & mental conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
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I understand and agree
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