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Home
About
Resources
Shop
Coaching
- 1-on-1 Coaching
- Self-Paced Coaching
Research
Blog
Contact

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Application Form for Cancer and Intimacy Coaching

Welcome! I’m honored that you’re here.
This form helps us begin from a place of shared care, clarity, and intention so we can determine if working together feels like the right fit for your healing and growth. If you are in a partnership, I ask that each of you submit an application separately.
Thank you!

Section 1: Basic Information

Full Name

Please indicate the name of your partner if you're both submitting intake forms for coaching work

Preferred Pronouns

Email

Phone Number (for reminders/emergency contact only)

Time zone

How may I be of service?

What has inspired you to seek coaching and how may I be of service?

Section 2: Cancer & Healing

Where are you (or your partner) in the cancer journey?

In active treatment Recently completed treatment In long-term recovery/remission Partner of someone going through cancer Other

If Other, please describe

What are some current physical/emotional impacts you’re navigating? (Select all that apply)

Fatigue Pain or nerve sensitivity Low libido or arousal changes Body image challenges Fear or anxiety Grief or loss None of the above Other

If Other, please describe

Section 3: Intimacy & Communication

If presently in a relationship, how would you describe your current connection?

Emotionally strong, physically connected Emotionally connected, sexually disconnected Physically close, emotionally strained Disconnected or uncertain Other

If Other, please describe

If presently in a relationship, how often do you talk about intimacy or touch?

Often – openly and comfortably Occasionally – it comes up sometimes Rarely – it feels hard to talk about Not at all – we don’t talk about it yet

If presently not in a relationship, what is your comfort level with intimacy or touch?

I feel very comfortable with intimacy and touch, even outside of a relationship. I feel somewhat comfortable, depending on the context and connection. I feel cautious and prefer to take things slowly. I feel uncomfortable and tend to avoid intimacy or touch. I’m unsure / still exploring how I feel about intimacy and touch right now.

Please share more here:

What do you hope to gain from our coaching work together?

Section 4: Previous Experience(s)

Which of these concepts are you familiar with? (Select all that apply)

Erotic Blueprints™ Wheel of Consent Urban Tantra or other Tantra-based practices Trauma-informed coaching None, but we’re curious Is there a similar modality or framework that’s not listed here that you’ve explored together?

If there is a modality that you've explored indivudally or together that might inform our work, please share

Section 5: Final Reflections

Please share with me anything else you'd like me to know before we meet. You can also put any questions you have here.

Please schedule your complimentary 20-minute Clarity Call if you haven't already so we can go over your coaching application together. You can do that here: Book your Clarity Call

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