Somatic Sex Coaching Intake Form - Charlie Glickman PhD

Name

Phone

Website

How did you hear about me?

Challenging things from your sensual/sexual history that you want me to know are:

Wonderful things from your sensual/sexual history that you want me to know are:

Wonderful things about your current sexuality that you want me to know are:

Please list any medical conditions that affect your sexuality:

What would you like to tell me about your current intimate relationship/s?

If you have a partner, do they know that you will be receiving somatic sex coaching? Would you be interested in having them join you for some of the sessions?

Please tell me about any previous experience with sex therapy and/or sexual bodywork (such as sexological bodywork, sensual massage, sex work, surrogate, tantra, etc.). If you are currently working with a therapist, do they know that you are interested in somatic sex coaching?

What else would you like me to know about your sexual history or current desire patterns, including gender identity, sexual orientation(s), self-pleasuring practices, fantasies, use of pornography, or any other information that you feel may be important for me to know?

Please share any experiences you’ve had with sexual assault or trauma that you feel might affect our work together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.

If relevant, please share any history you have of pregnancy, labor and delivery, miscarriage, or abortion that you feel might affect our working together. If you would prefer to have that conversation over the phone or in person, please make a note of that here.

How would you like to feel at the end of our work together?

What questions do you have for me? What would you like to know about somatic sex coaching, my experience and background, or anything else that might affect our work together?

I understand that any touch will be given only at my request and solely for my own benefit, education, and pleasure. I agree to guide touch to ensure that it is always beneficial, educational, and pleasurable for me. I understand that I am responsible for communicating verbally if I change my mind about something I have previously given consent for.

I understand that Charlie does not act as a surrogate partner.

I understand that somatic sex coaching can inspire many different feelings and thoughts, all of which are welcome during a session. I know that Charlie is not a therapist and I will seek appropriate care from a qualified professional, if I need it.

I understand that appropriate hygienic protocols will be used, including gloves for all genital and anal touch.

While Charlie and I may discuss my goals for our work together, I understand that Charlie can make no guarantees regarding outcomes.

I agree that I will be an active participant in my change process.

I have stated all medical conditions that I am aware of and will update Charlie on any changes in my health status.

I understand that drugs and alcohol are not compatible with somatic sex education.

I understand that payment for each appointment is due by the start of the session. If I cancel an appointment with less than 24 hours notice, I agree to pay Charlie the regular fee.

I am over 18 years old.