Midwife For Your Sex Life
This form is the first step toward working together. Your answers help me understand where you’re at, what you’re needing, and how I can best support you. Once your submission is receive you will receive a follow up email within 24 hours with next steps.
Name
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First Name
Last Name
Pronouns
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What made you interested in my services?
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Are you interested in...
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A single session coaching (one-time deep dive)
A single session counseling (one-time deep dive)
Ongoing coaching (weekly, biweekly, monthly, etc.)
Ongoing counseling (weekly, biweekly, monthly, etc.)
Sex Ed Starts at Birth early parenting support
Pre-period/puberty prep
Tween/Teen support
What Time Zone Are You In?
Preferred days/times for sessions (check all that apply):
Preferred days/times for sessions (check all that apply):
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
My schedule is unpredictable — let’s talk about it
What are you hoping to work on or explore in our sessions?
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Libido/desire
Body image or body reconnection
Navigating sex in pregnancy
Navigating sex after baby
Touch aversion or feeling “touched out”
Pleasure exploration
Shame or discomfort around sex
Partner resentment/mental load impact
Perimenopause
Sex Education
Menstrual Cycle Education
Cycle Syncing
PMDD Coaching
Which stage of mother/parenthood best describes you right now?
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Pregnant
Postpartum (0–12 months)
Postpartum (1+ years)
Parenting young kids
Parenting older kids or teens
Perimenopausal
Not sure / Other
Have you ever worked with a coach, therapist, or provider around sexual health or intimacy before?
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Yes
No
Other
If you are a parenting wanting services for your child, have they received any education/guidance so far?
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Yes
No
Other
(Optional: If yes, feel free to share what that was like or why you’re seeking something different. Write N/A if not)
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If you are inquiring about parenting services, how old is your child/children)
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How do you want to feel by the end of our work together?(Open text – give them space to dream a little)
*
Anything else you’d like me to know?
Submit
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