Client Intake Form

Client Intake Form

Name Email Phone Number
Skype Name
How did you hear about me?
Are you presently under the care of a physician or therapist?
Are you presently taking any medications other than non-prescription pain relievers?
If yes, what medication(s)?
What are you seeking? What is your goal?
What is holding you back?
What is your commitment level? (on a scale of 1-10, 1 = lowest, 10 = highest)
What will happen if nothing changes?
What was it that motivated you to contact me?
What symptoms or details do you want to share with me regarding your situation that will help me understand what you are going through?
What specific results would you like to obtain from this process?
Have you worked with another coach/counselor/mentor/healer before?
(if "No" answer N/A to the next 3 questions)
If yes, what was helpful to you that the sessions provided?
What do you feel you accomplished from these sessions?
What do you feel was not helpful, or why did you not obtain the results you desired?
What are your strengths?
What areas would you like to be strengthened?
Do you have a support system (spouse, family, friends, or colleagues)?
What will you do to make sure that you get the most out of your sessions with me?
Do you feel ready to make changes and resolve what's preventing you from healing and becoming your potential?
Additional Comments



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Sunyata Satchitananda

Counselor, Coach, Certified Sexual Healer at Sunyata Satchitananda
Sunyata is a Spiritual Counselor, Certified Tantric Healer and Author of "Safe Sexual Healing: a Guidebook for Healers and Clients." Ordained Minister (1980), Certified Tantric Healer (2007), Reiki Master (2009). Sunyata specializes in helping men and women achieve deep transformation, spiritual growth, sacred sexuality, heal from sexual abuse and emotional trauma, and develop a greater, deeper intimacy and connection with their partner.
Sunyata Satchitananda

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