JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Talk Sex with Dr. Lexx--Guest Application
Please fill out the following information completely. Talk Sex with Dr. Lexx needs all the information requested to consider if you're a fit for the show.
* Indicates required question
Email
*
Your email
Names and pronouns of people to be on podcast (ex. ( She|Her|Hers), (He|Him|His), (They|Them|Theirs)
*
Your answer
Please write the phonetic pronunciation of you and your partner’s full name
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
Can we identify ourselves as Talk Sex with Dr. Lexx if/when we call you at this number or leave a voicemail?
*
Yes
No
Email of your partner
*
Your answer
Can we identify ourselves as Talk Sex with Dr. Lexx if we email you?
*
Yes
No
Race of you and your partner
*
Your answer
Gender of you and your partner
*
Your answer
Current relationship status to each other (checkboxes)
*
Single
Married
Divorced
Widowed
Monogamous
Polyamorous
Long term relationship
Situationship
Entaglement
Separated
Other:
Longevity of current relationship
*
Your answer
Has there been any infidelities in the relationship
*
Yes
No
Maybe
If yes to the previous question, whom and when?
*
Your answer
Please explain in detail what situation brings you to Dr. Lexx.
*
Your answer
How long have you dealt with this situation/condition/issue?
*
Your answer
What would you like Dr. Lexx to help you address specifically?
*
Your answer
Are you interested in being connected with continuing therapy services after your episode records?
*
Yes
No
Maybe
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Institute for Sexuality and Intimacy.
Report Abuse
Forms
