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The Sex Therapy Intake form.

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Are you in a committed relationship?

Yes, married.

Yes, engaged.

Yes, in informal relationship.

No, I'm single.

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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.

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Do you reach orgasm?

Yes

No

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How long does it take you usually to orgasm?

Way less than 30 minutes.

About 30 minutes.

More than 30 minutes.

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How long do you take for foreplay?

5-10 minutes

20-30 minutes

30+ minutes

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Do you discuses sexual issues outside sexual intercourse?

Yes

No

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