Sexual History Intake

Please answer as many questions as you can, especially if seeking sex-specific therapy. Detail is not needed on this form, rather this will be used for an in-depth conversation in session to help with the treatment process.

All fluidity, expression, verbiage, history, orientation, etc. is accepted and celebrated at this practice.

*This practitioner is a mandatory reporter and as such, please be aware that thoughts of harming others or self are not reportable, though may result in further exploration and enactment of a safety plan. This is a safe space to talk about fantasies, desires, kink, BDSM, sexual exploration, open relationships, etc. The ACTUAL past or present ACTION or future INTENTION or PLAN to harm someone who is underaged, elderly, disabled, or considered unable to protect themselves will be reported to appropriate authorities to ensure the safety of all. Please feel free to ask any clarifying questions before proceeding. This office is not properly trained in sexual offenses and will refer to appropriate services if needed. Please acknowledge your understanding below:

Describe your gender:

Gender assigned at birth:

Describe your sexual orientation:

Illnesses affecting sexuality:

Medications affecting sexuality:

Current stressors:

Pain with sex:

Issues with sex:

Number of completed pregnancies:

Number of terminated pregnancies:

Pregnancy complications:

Sexual Trauma (Y/N & ages, but no detail is needed):

Would you consider your Family or Origin (FOO) and childhood home to have been more sexually positive or negative?:

What are your FOO religious and/or spiritual beliefs about gender and sexuality:

Attitudes of sex and gender with FOO and environment:

Cultural attitudes of sex:_

How did you learn about sex?:

How did you feel about puberty?:

History of sexual insecurity:

Insecurities with your body

Insecurities with sexual expression:

Current spiritual support of your sexuality:

Age started masturbating:

Feelings about masturbation when started:

Current masturbation frequency:

Current feelings about masturbation practice:

Current use of pornography: _

Feelings about pornography:

Total number of sexual partners:

Number of current, active sexual partners:

Any sexual behaviors that are distressing?:

Sex Thoughts that are distressing?:

Current relationship sexual satisfaction or issues:

Current sex drive:

Partner’s sex drive: _

How do you feel talking about sex?:

With partner?

Thoughts about the place/purpose of sex in a person’s life:

Thoughts about the place/purpose of sex in relationships:

What does healthy sex mean to you?:

Do you have any questions about sex?:

Select a date

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