Full Name

Pronouns

Preferred Name

Sex [radio* sex use_label_element “female” “male” “intersex”]

Gender [radio* gender use_label_element “female” “male” “nonbinary”]

Home Address

Phone Number

Text Message OK? YESNO

Email Address

Emergency Contact (Name, Phone Number, Relation)

Your Therapist’s Full Name

Your Therapist’s Email Address

Your Therapist’s Phone Number

Length of time with this therapist?

Why did you and your therapist decide to begin Surrogate Partner Therapy?

Describe any past or current mental health clinicians or practitioners that you have worked with.

Please write down specific goals that you would like to accomplish during our work together. List them in order from most important to least important.

List any chronic mental/physical health conditions, disabilities that you have or specific accommodations you require.

Tell me about your intimate relationship(s). Current or past, whatever is relevant and important.

Describe the sexual education and messages you received about sexuality while growing up.

On a scale of 0-10 (0 = No acceptance, 5 = Moderate acceptance, 10 = I love and accept my body exactly as it is), how well do you accept your body as it is?

Add details about your body image.

Describe any past sexual abuse or trauma that I should be aware of.

Please add anything else you would like me to know about your sexual history or current desire patterns, including gender identity, sexual orientation(s).

Describe your self pleasuring practices, fantasies and use of pornography. What are they and how often, if any?

Do you have difficulty orgasm with or without a partner?

Do you have difficulty finding or staying in relationship?

Describe your ideal relationship or intimate connection?

Lastly, tell me what is the most wonderful thing about yourself you want me to know!