Questionnaire for intimacy coaching clients Keva Massage – Intimacy Coaching Questionnaire for Keva Massage’s intimacy coaching clients. "*" indicates required fields Step 1 of 6 16% Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What are your goals for intimacy coaching? What is intimacy to you?What is sex to you?What is your sexual orientation? Who are you attracted to? What are you attracted to? What turns you on?What are your intimate fantasies?What are your sexual fantasies?Describe a bad intimate encounter you've had.Describe a good intimate encounter you've had.What are your hard no's? Have you experienced sexual trauma?I don't knowMaybeNoYesHave you experienced trauma in general?I don't knowMaybeNoYesHave you been the perpetrator of abuse?I don't knowMaybeNoYesDo you have children?NoYesDo you want them?I don't knowMaybeNoYesHave you ever had an abortion or impregnated someone who had?I don't knowMaybeNoYesAny miscarriages or pregnancy loss?NoYes Are you in a relationship?NoYesIt's complicatedWhat does your ideal relationship look like?Describe your past relationship?What is a healthy relationship?Who is your support system? What brings you joy?What hobbies do you have? Have you been in therapy?NoYesWhy not?What was your experience like?Do you have any medical diagnoses?I don't knowNoYesDo you have a physical limitation?NoYesDo you take medication?NoYes Would you describe yourself as happy?NoYesMaybeI don't knowWould you describe yourself as confident?NoYesMaybeI don't knowOn a scale of 1-10 with 10 being the highest, what is your level of self-esteem?Please enter a number from 1 to 10.Would you describe yourself as an attractive person?NoYesMaybeI don't knowWhat do you do for work? Do you enjoy work?NoYesMaybeI don't knowWhat is your purpose? Do you feel like you have one? (It's ok to say no.)
