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The Sex Therapy Intake form.
What is your name?
*
What's your phone/WhatsApp number?
*
What's your e-mail?
*
What's your age?
*
Are you in a committed relationship?
*
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.
How long do you take for foreplay?
*
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?
*
Submit