Name (first name is fine):				Email:	
Phone:				Age				Sex
Status:  married / single / cohabitating / widowed / divorced / separated /   poly / open / it’s complicated	
Sexual orientation:  straight / gay / bi / asexual / not sure / other

I’m interested in (check all that apply):
	general dating guidance
	intimacy coaching
	sex ed, basic
	sex ed, advanced
	Surrogate Partner Therapy
	not sure / it’s complicated

Missing in my life (check all that apply):
	romance / passion
	fun / play
	emotional intimacy
	physical intimacy
	companionship
	appreciation / feeling needed
	sensuality / body awareness
	sexual experience / skills
	communication skills
	dating strategies / “game”
	a tribe / social circle
	a confidante
	positivity / optimism
	structure / stability
	intellectual stimulation
	creative inspiration

My best qualities are (check all that apply):
	passion
	self-awareness
	communication skills
	empathy / warmth
	ambition / drive
	success / security
	supportive / dependable
	intelligence
	loyalty
	integrity
	forgiving / flexible
	energetic
	fun or funny
	sociable / outgoing
	mojo / sex appeal
	creative, talented, or skilled (in some way)
	generous (with time or anything else)
	unique / unconventional in a good or interesting way

I have (check all that apply):
	been in love
	never been in love
	had my heart broken
	healed from a broken heart
	become stuck in grief
	  become stuck in fear / anxiety

Re: online dating: I have:
	tried it with positive results
	tried it and ran for my life
	not tried it and want to
	not tried and am scared to
	not tried, not interested

My worst experience dating &/or being intimate (2-3 sentences is fine, more if needed):

My best experience dating &/or being intimate (2-3 sentences is fine, more if needed):

My main obstacles to better dates / sex / intimacy
(e.g., shyness, inexperience, disability, no time/overworked, depression, lingering divorce, unsure, etc.):

I need help with (check all that apply):
	unreliable erections / ED
	premature ejaculation (lifelong)
	premature ejaculation (acquired)
	inhibited (delayed/blocked) ejaculation
	inexperience
	late-in-life virginity (25-70+)
	performance anxiety
	low libido or diminished pleasure
	communication (conveying my needs)
	technique (understanding my partner’s)
	dissociation
	confusion
	body image
	desire discrepancy (with my partner)
	dating & seduction skills
	other(s)  	

Things I’ve tried (check all that apply):
	medical exam, medication
	talk therapy
	sexuality & relationship workshops or coaching
	books / articles / research
	sexual aids 
	fantasy, role play
	alternative sex practices (BDSM, swinging, fetish, etc.)
	erotic service providers
	other(s)  	
	nothing yet

My primary goal or vision for how this coaching might change my life:______________________________________

Anything else you’d like to share:___________________________________________________________________

_____________________________________________________________________________________________

Available for coaching at (check all that apply):
	KC’s Austin studio
	client’s Austin hotel

I have reviewed KC’s rates and:
	they’re in-line with my budget, should I choose to proceed. I will not schedule a phone consult or session before taking this vital first step.