Vaginismus Intake form

KIA ORA, I'M LOOKING FORWARD TO WORKING WITH YOU.

I'D LOVE YOU TO ANSWER A FEW QUESTIONS BEFORE OUR SESSION:

Name

First Name

Last Name

Phone

What are you currently experiencing in your body? Specifically your vulva and or vagina?

What do you most want to get from our time together?

Are you currently suffering from any physical or emotional symptoms related to a traumatic experience? Y / N If yes, please explain:

Please let me know if there is anything else you would like to know or would like me to know:

By signing this form I agree to the below:

By signing this form you agree to all the below * Somatic sex education is not psychotherapy or medical treatment I understand that any erotic touch will be given only at my request and solely for my own benefit, education and pleasure. I have stated all medical conditions that I am aware of, and I will update Morgan on any changes in my health status. CANCELLATION POLICY - If you need to cancel your appointment this has to be done 3 days prior to session time for you to receive a refund. Cancellations or Rescheduling within the 24 hours prior to appointment time will incur a fee of $50 IN THE CASE OF YOUR PRACTITIONER RESCHEDULING YOUR SESSION - If for some reason your practitioner needs to reschedule your session a new time will be arranged and your payment will be carried over. In the case that your practitioner needs to reschedule and you are unable to find a new time that suits you both, your practitioner will refund your payment. Thank you for understanding and respecting my work by honouring this agreement.

Yes

Vaginismus Intake form

KIA ORA, I'M LOOKING FORWARD TO WORKING WITH YOU.

I'D LOVE YOU TO ANSWER A FEW QUESTIONS BEFORE OUR SESSION:

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