Sexual Awareness Survey

First & Last name + Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Have you read and understood my etiquette and the services I provide?*
What is your intention in receiving Tantric Healing? ie: to receive pleasure? To relax/work on specific sexual goals? To explore your full capacity for pleasure and become sexually masterful?*
Do you have any of the following? Erectile dysfunction, Inhibited ejaculation, anorgasmia? Trouble getting hard, staying erect? *
If you have ED have you had physical symptoms checked by your medical doctor? What did your doctor prescribe? have you had bloodwork?*
Do you strengthen your pelvic floor muscles with power wind exercises or sexual yoga practice?*
Have you had prostate cancer or had your prostate removed?*
Do you drink alcohol? If yes, how many drinks a week?*
Please list any recreational drug use; ie Marijuana, cocaine *
How do you manage and release stress?*
Do you exercise? How many times a week?*
Do you practice meditation/breathwork?*
Do you watch porn? How many times a week?*
If you are struggling with erectile difficulties are you ready willing and able to commit to making the necessary changes in your lifestyle? I recommend 6-12 weeks of home-play and online or in-person sessions.*
Do you have any significant or current relationship issues at the moment that are affecting your self esteem,*
Are you aware of any sexual shame that you would like to clear? If not, how long have you been actively working on healing your sexual shame? *
How do you feel about seeing a sexual somatic Tantrika?*
Are you clear that I do not provide sexual services and that if you choose my somatic bodywork it is meant only for you to receive and learn how to embody your sacred sexual masculinity? *
Do you understand this is a professional relationship? If boundaries are not respected the client/therapist relationship will be terminated. *
Should be Empty: