Intake Form

Thank you for booking a session. Please set some time aside to fill out this form as completely as you can before your appointment. This is a secure form; your information will be kept private in accordance with my privacy policy.

If you have not yet booked a session, click here or email hello@sexcoachshannon.com to get started.

Name & Pronouns (required)

Email(required)

Phone Number

Age

Gender

Sexual Identity

Relationship Status

Occupation/Hobbies/Passions

Religious Affiliation/Observances (if any)

How satisfied are you with your mental & emotional well-being?

How satisfied are you with your most intimate relationship?

Have you seen or are you currently seeing a psychotherapist or counselor?

Please list any medical or psychological conditions that may be affecting your sexuality, intimacy, or relationships:

How might what you have been taught about sexuality be affecting you?

How does your self-image affect your sexuality?

In as much detail as you would like, please share your sexual relationship history (number of partners, sexual activities, issues, conflicts, etc.):

What is your current situation and satisfaction level in regards to sex and intimacy?

What are your sexual interests and desires, and how are they being met?

When was your last orgasm?

What are your sexual road-blocks, turn-offs, or conflicts?

What are your expectations for our session?

Sex coaching assists clients with matters such as sexual intimacy, personal challenges, and relationships. A coach is in a partnership with the client to help improve their personal life. The focus is to help the client consciously create a vision and goals for life. Coaching helps clients think differently and learn what’s best for the individual. Coaching is not therapy nor counseling.

These services do not include the practice of medicine or psychology or counseling. I, as a client, agree that I am fully responsible for my physical, mental and emotional well-being, including my choices and decisions while engaging in these services. If I am under the care of a mental health professional, I will make the mental health professional aware of my sessions with Shannon Burton. If any type of counseling or mental health treatment is needed, the client is to be referred to individuals who provide that care.

I understand that identifying personal information will be held as confidential except as required by law.

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