Sexual Issues Counselling

Your Name: 

e-mail address:  

Your sex:     Male        Female

Your Partner's name:
(If you're not on a current sexual relationship, indicate "none.")

Partner's Sex:
(only required if you are in a sexual relationship)   Male        Female

Tell us what you'd like to work on:

Tell us about the duration of this issue:

How have you dealt with similar issues in the past?

Tell us a bit about yourself (age, family of origin, relationship(s) you're presently in, medical conditions you've had or are prone to, where you carry stress in your body, etc.) Please also provide us with a brief sexual history.

We will be contacting you be e-mail. Are you comfortable that your e-mail is sufficiently private? If you click "yes" we will respond to the above e-mail address with our assessment. If "no," please use the following box to suggest an alternative way (i.e. FAX to communicate with you.)

Yes            No

Alternate arrangement suggestion (optional field)