Consultation

First name(s) of interested parties*

Age range (Check all that apply if this is for more than one person)*

21-2627-3233-3940-4748-5556-6263+

Gender (Check all that apply if this is for more than one person)*

FemaleMaleTransgenderGender fluidNonbinaryNot sure

Sexual orientation (Check all that apply if this is for more than one person)*

HeterosexualLGBTQPansexualAsexualNot sure

Problem (Check all that apply)*

Erectile functioning issuesLow libidoLack of interestLow confidenceLack of response to sexual stimulusInability to reach orgasmExcessive libidoTrauma or sexual traumaInability to control sexual behaviorDistressing sexual thoughtsUnwanted sexual fetishesRecovery from infidelityIssues with the relationship power dynamicIssues related to consensual non-monogamy

Are you/partner receiving any ongoing mental health care?*

YesNoConsidering it

Are you/partner receiving any ongoing medication management?*

YesNoConsidering it

Will this be for individual services or a couple?*

IndividualCouplePolyamorous/nonmonogamous

Additional helpful information (max 300 words)*

Email address for contact*