Name You Most Prefer
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nicknames/petnames welcome
First Name
Last Name
Email
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Phone
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(###)
###
####
Date of Birth
MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
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Name, Relationship, Phone Number
Sexual Orientation
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What is your preferred pronoun?
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What country were you born in?
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What city/state/country did you grow up in?
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What is your relationship status?
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How did you discover my services?
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Who referred you? (if any)
Do you have any allergies/sensitivities to foods, medications, animals, latex, rubber, or plants?
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Do you have any bodily limits or surgical history that are relevant to the practical awareness?
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Approximate Height
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Approximate Weight
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Current Occupation
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Do you have any religious/spiritual practices? If so, please list.
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Do you have a current therapist, coach, healer or priest? If so, please list.
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Did a parent or other adult in the household often (or very often) push, grab, slap, or throw something at you, or ever hit you hard enough to leave marks or cause injury?
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Did a parent or other adult in the household often (or very often) swear at you, insult you, put you down, or humiliate you?
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Did a parent or other adult in the household often (or very often) make you feel as though you weren't loved, important, or special or that your family didn't look out, support, or feel close to each other?
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Did you often (or very often) feel that you didn't have enough to eat, didn't have clean clothes to wear, or anyone to provide for you?
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Were your caretakers ever too inebriated to properly take care of you or take you to the doctor/dentist if you needed it?
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Were your parents ever divorced or separated?
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Did you ever live with someone who was an alcoholic or problem drug user?
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Have you ever been sexually assaulted?
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Have you ever had suicidal thoughts or ideation?
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Have you ever attempted suicide?
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Do you take any medication or over the counter medicine?
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Are there any parts on your body that are particularly sore or in need of special attention/awareness?
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Do you exercise and stretch on a regular basis?
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In your daily life, would you call yourself a risk taker?
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Is it often you're willing to explore, sometimes even push/ride the edges of your limits and boundaries; or do you stick to your comfort zone?
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Have you ever been admitted to a rehab or detox facility?
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How many hours a day do you spend alone?
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Are you content with your current life situation?
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How do you express yourself? And how often do you do these activities?(dancing, singing, playing an instrument, etc.)
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How do you release stress or relax? How often do you prioritize these two things?
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Are you satisfied with your ability to be honest, real, YOUrself?
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Are you sexually active?
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Do you experience difficulties expressing or feeling your emotions?
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What is your go-to emotion?
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What do you think is your most repressed emotion?
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Are you more visual, auditory, or kinesthetic?
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What 's the first thing that comes into your mind when you think of "bondage"?
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What ideas, associations, beliefs, memories, and sensations come to mind when you see word "submission"?
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Have you ever been tied up/bound against your will?
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Have you ever been locked in a closet, box or small space?
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Is it difficult for you to say NO or speak your boundaries?
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In the Karpman Drama Triangle: Persecutor/Victim/Rescuer, where do you land most often?
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Have you ever experienced wanting to say NO, but couldn't?
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Are you currently, or have ever been a people pleaser?
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Do you ever (or often/sometimes, in the past or present) have sex without feeling 100% yes to it, because you feel you have to?
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Do you ever (or often/sometimes) regret having sex? If so, why?
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Briefly describe your support system (friends, relatives, community, shaman, healers, therapists, etc.)
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Are you feeling settled or more in transition? (Moving from current city/state, breaking up or divorcing, new job or work position)
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When you feel upset, activated, anxious, overwhelmed, etc. do you reach out for support or do you withdraw?
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Are you open about sharing this experience with your close circle or do you keep it private? Will anyone know about this experience? Are there people who would be against this type of exploration so you'd rather keep it quiet?
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How do you want this session to impact your life?
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Are you able to make time for integration and self-care after our session?
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