Couples Intake Form

First Name *

Last Name *

Partners Name

Enter Email *

Skype ID *

Phone Number *

How long have you been together? *

Do you have Kids? If so, how many and how old? *

On a scale from 1-10 how would you rate your current sexual experience together? *

What areas of your sex life do you enjoy the most together? *

What are the three biggest challenges you are experiencing in your sex life? *

What are you most looking to change in your sexual relationship? *

If you could get one thing from our time together, what would it be? *