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Sex Therapy Intake form

What is your name?

*

What's your phone/WhatsApp number?

*

What's your e-mail?

*

What's your age?

*

Have you had an FGM

*

Have you had an FGM

Yes

No

Are you in a committed relationship?

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Are you in a committed relationship?

Yes, married.

Yes, engaged.

Yes, in informal relationship.

No, I'm single.

Are you sexually active?

*

Are you sexually active?

Yes, I have a sexual partner.

Yes, I have several partners.

Yes, I masturbate.

No, I don't have a partner or masturbate.

Do you reach orgasm?

*

Do you reach orgasm?

Yes

No

How long does it take you usually to orgasm?

*

How long does it take you usually to orgasm?

Way less than 30 minutes.

About 30 minutes.

More than 30 minutes.

What type of orgasm do you experience?

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What type of orgasm do you experience?

Clitoral

Vaginal

Nipple-stimulation

Hands-off

Other

How long do you take for foreplay?

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How long do you take for foreplay?

5-10 minutes

20-30 minutes

30+ minutes

Do you discuses sexual issues outside sexual intercourse?

*

Do you discuses sexual issues outside sexual intercourse?

Yes

No

Why?

*