Intake Form

Please take the time to fill out this intake form to help us better understand your needs and provide the best service you.

First Name

Email Address

Last Name

Date of Birth

Do you have a yoga practice? If so, how long?

Are you familiar with the practice of Tantra and if so, what is your experience or understanding of or with Tantra?

What are three goals you would like to accomplish from these sessions?

In one sentence, describe your diet.

In one sentence, descibe you exercise regimen.

On a scale of 1-10 how would you rate your stress level on a daily basis?

On a scale of 1-10 how would you rate your sex life?

On a scale of 1-10 how would you rate your emotional life?

On a scale of 1-10 how would you rate your physical health?

On a scale of 1-10 how would you rate mental health

Do you have a spiritual practice?

Have you ever been pregnant?

Do you have any children?

Do you have any injuries or health concerns?

On a scale of 1-10 how healthy would you say your urogenital system is?

Is there anything you would like to share that may assist in developing a program for you?

What are some of your hobbies? Favorite foods? Last book you read?

Do you have any relationship, career, or personal goals you are working to accomplish this year? If so, what are they?

What do you think your life's purpose is?

Thanks for submitting!