Tantra Healing for Couples Intake

Tantra Healing for Couples

Intake Form

The form below consists of a series of questions designed to help us (Dr. Erickson and Devi) assess how we can best support you during this course and help you achieve your desired outcome from this course.

You are not obligated to answer all or even ANY of the questions.

If you choose to answer these questions please know that your answers will be reviewed by Dr. Erickson and Devi ONLY unless you request additional support sessions with another instructor. At that time you may give consent for these answers to be shared with your support coach if you desire. Please submit your answers no later than September 10th at 11:59pm in order to be reviewed by us by the first class. Thank you!

Tantra Healing for Couples Intake

Name *

First

Last

Partner Name *

First

Last

Primary Email *

Location *

Your Ages

How long have you been together?

Do you have children? If so, how many and what are their ages?

Do either of you have any current, recent, or past health issues that interfere with your quality of life?

Are either of you currently taking any medications, prescriptions, or supplements?

Do you or your partner have any diagnosed mental health issues?

Are you or your partner a trauma survivor or have you experienced any overt trauma such as sexual assault, abuse, accidents, etc.

Did either of you grow up in a religious household? If so, what was the religion and how do you feel that impacted you?

On a scale from 1-10, how would you rate your current experience of intimacy as a couple? Intimacy can mean sexual, emotional, psychological, spiritual intimacy.

What do you love MOST about your relationship? Please name 1-3 things each

What area(s) of your relationship would you most like to improve? Please name 1- 3 things each.

What are 3 things you would like to achieve through taking this course? For yourself and your relationship.

Thank you for taking the time to fill out this form. Is there anything else you'd like for us to know?