Sustainable | Healthy | Living - Tantra Yoga Intake

Tantra Yoga Questionnaire

Questions / Answers, Shared Understandings and Agreements

Imagine you’re writing in your personal diary. Share to your comfort level as much as possible and withhold to your comfort level as well. There is no right/wrong answer.

Client Statement of Responsibility and Liability Waiver:

Tantra yoga session are deeply spiritual and may be physically intimate and I understand that the Tantra yoga sessions facilitated by the coach are completely non-sexual.

Sometimes strong emotions, memories or sensations arise and it is up to me (the client) to decide if I want to pause or stop or if I want to work through them. By scheduling a session I agree to take full responsibility for my choices and release the practitioner from any liability regarding anything related to the session.

I agree to tell the session facilitator immediately and clearly if I am experiencing discomfort or want a pause or to stop the session. I understand that the intention of this session is to bring about a profound integration of spirituality, sensuality, and self-love, supporting a clear flow of energy through my body and a sense of connection to my body, breath, and soul.

Please Select One:

I Consent

I Do Not Consent

1. What I hope to achieve through my Tantra yoga sessions as an individuals and/or as a couple is...

2. My recent and current emotional and physical state can be described as...

3. Do you have any ongoing sexual relationship/s?

Yes

4. If yes, are there any issues you are currently working through in your relationship?

5. Describe important past relationships:

6. Please list previous and current illnesses or medical conditions including psychological / emotional conditions:

7. Please list any medications (prescription, over-the-counter, herbal, or plant medicines) taken, and what they are for:

8. Briefly list any physical, emotional, verbal, or sexual abuse/trauma you may have experienced at any point in your life:

9. What brings me pleasure physically... sensually...& sexually is...

10. Do you have any kind of hormonal imbalance/conditions? Please describe:

11. Please describe your diet. Do you consume meat, dairy, garlic, processed foods (junk foods), processed sugar, coffee, wheat, or gluten?

12. Do you have food allergies, food intolerances, or special requirements? Describe.

13. Do you have any addictions (alcohol, cigarettes/nicotine, marijuana, gambling, sex addiction, porn addiction)? Please describe:

14. Have you had gender reassignment?

15. What is your sexual orientation and identity? (heterosexual, homosexual, bisexual, pansexual, transgender, non-gender, non-binary, non-conforming, cis)

16. Do you have any hernia or abdominal issue that could create a risk during abdominal massage or touch? If yes, please describe:

17. Are you sensitive or averse to touch or pressure? Please describe.

18. Please describe any religious conditioning you received regarding sexuality:

19. Please describe any cultural/societal/ethnic/parental conditioning you received regarding sexuality:

Client Statement of Responsibility and Liability Waiver Sometimes strong emotions, memories or sensations arise and it is up to me (the client) to decide if I want to pause or stop or if I want to work through them. By scheduling a session I agree to take full responsibility for my choices and release the practitioner from any liability regarding anything related to the session, physically, emotionally or mentally. I agree to tell the session facilitator immediately and clearly if I am experiencing discomfort or want a pause or to stop the session. I understand that the intention of this session is to bring about a profound integration of sexuality and spirituality, supporting a clear flow of Chi through my body and a sense of oneness in all that I am.

Client Name

Client Signature

Date

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Client Name

Client Signature

Date

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