Session Request

These days I am very busy working on video and book projects as well as studying and teaching. I would love to talk with everyone who has an interest in my practice, however I have a limited amount of time and energy.

Therefore, I request that if you are interested in a session with me please fill out my Session Request below so that I can learn a little more about you. After we communicate via e-mail we will speak on the phone before booking the appointment as I like to have a feeling of the person that is coming to see me. Please also keep in mind that I have a 24 hour advance notice cancellation policy.

I am available mainly weekdays from 10-7. I can occasionally book a session in advance for an evening or weekend.

Your privacy is of the utmost importance to me as is mine. You can rest assured that any personal information you share with me will be held in the utmost confidence and in the securest way possible. My absolute discretion and your complete privacy is guaranteed.

Every session with every new client begins with a formal in-take so we can establish our rapport, intentions, and context for your healing session.

Name *

First

Last *

Last

Email *

Add me to your mailing list *

Yes

No

Mobile Phone *

Other Phone

What's the best way to reach you? *

Best time to reach you *

AM

PM

Is it okay to leave a message?

Yes

No

Gender Male Female Couple

Birthday MM/DD/YYYY *

City/Prov or State *

How did you find me? * Google Backpage Craigslist Goddess Temple Sacred Eros Reference Other

Details

Referral Name

Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe

Are you familiar with my website, especially the session descriptions and rates? *

Yes

No

If not, please go back and read session descriptions and rates sections before contacting me

Type of Session *

Blissful Bodywork

Blissful Bodywork & Education

Couple Bliss

Goddess Bliss (women)

Tantra Immersion

Intimacy Coaching

Intensives

Double Goddess

Date of Appointment *

Time of Appointment *

Length of Appointment * 1 hour 1.5 hours 2 hours (first session recommendation) 2.5 hours 3 hours 3.5 hours 4 hours 6 hours

Have you been to see any tantric practitioners, sensual masseuses, or escorts before? *

Yes

No

If so, would you mind sharing who you saw and what the experience was like for you?

What intimate relationships if any are you involved in right now and how do you feel about them? *

Are you willing to accept full responsibility for your health, well-being, and personal pleasure? *

Yes

No

Maybe

If not, please go back and read session descriptions and rates sections before contacting me

What previous experience do you have if any with Tantra, Yoga, Meditation, Energy Work, or spiritual studies? *

Do you have any contagious illnesses including HIV, STDs, skin ailments, etc.? Please answer truthfully, so that we can take whatever precautions may be necessary to have a safe and healthy experience together. *

What are your reasons for seeking a session with me, and is there anything specific you would like to work on? *

i.e. relationship or intimacy issues, premature ejaculation or impotence for men, frigidity or lack of orgasmic response for women.

Do you have any physical concerns or medical issues I should know about? *

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