New Client Form | Modern Anarchy

Pleasure Practice New Client Form

Please provide the following information and answer the questions below. If anything does not apply to you simply write N/A or leave blank. Feel free to skip any questions you are not comfortable answering or place a star next to anything you would like to talk about but do not want to write down.

Personal Information

First name

Last name

Address

Phone

Gender

Pronouns

Age

Date of Birth

Race and Ethnicity

Sexual Orientation

Relationship Orientation

Occupation

Ability status: Do you identify as being differently abled or having a disability?

Do you have a history of mental health issues or are you currently in therapy for mental health concerns?

Do you have any medical conditions that may affect your relationship to pleasure?

Are you currently taking any medications? If so, for what conditions?

Emergency Contact

Emergency contact name and relationship to you

Phone

Your Pleasure Practice

What myths or cultural messages about sex and relationships have influenced you, and which ones are you ready to rewrite?

Pleasure comes in many forms: physical, emotional, intellectual, and spiritual. What practices bring you joy, aliveness, or sensual delight?

If you could step fully into your most empowered, pleasure-filled sex life and relationships, what would that look and feel like?

What do you love most about the way you show up in your sex life and relationships?

What do you love most about your body?

What makes you feel the most alive, in alignment, and tuned in to yourself?

Imagine yourself at the end of our work together, feeling deeply connected to your pleasure. What has changed? What do you now know, feel, or embody?

What message of support or affirmation would you give to your future self as they step fully into their pleasure?

Consent

The Process

Pleasure-based coaching can be helpful in improving overall health, wellbeing, and quality of life. The Pleasure Practice provides coaching, education, and experiential guidance designed to support your relationship to pleasure and embodiment. These services are not psychotherapy, a diagnosis, or medical treatment.

Engagement in services is a collaborative process that requires a significant commitment of time and energy. Coaching works best when you are willing to share openly and explore with Dr. Nicole the feelings, thoughts, and experiences that arise over the course of our work together. This includes what you have noticed about the progress of your relationship to pleasure, feedback for Dr. Nicole around what is and is not working and what you would like more of, and any concerns you may have about our work together. At times, this may involve pushing your comfort zone, but generally results in better outcomes and a greater connection and alliance with Dr. Nicole.

I, the undersigned client, understand and consent to participate in pleasure-based coaching provided. I understand that coaching is not a substitute for psychotherapy or medical treatment. Although Dr. Nicole Thompson is a psychotherapist, in this context she is serving solely as a coach. This relationship does not establish a therapist–client relationship. Dr. Nicole will not provide a diagnosis, psychotherapy, or treatment plans.

I understand and agree to the fee structure, processing fees, and scheduling arrangements. I will make payments as agreed upon and adhere to the cancellation policy of 24 hours’ notice, or the full session fee will be charged and credit towards session minimums will be forfeited. By signing, I authorize The Pleasure Practice LLC to charge my credit/debit card in accordance with the agreed payment terms and cancellation policy.

Coaching may involve discussing sensitive topics, somatic exercises, or experiential practices that can evoke emotional discomfort. Participation in all practices is voluntary, and I may pause or withdraw at any time. Either the client or The Pleasure Practice LLC may choose to terminate the coaching relationship at any time for any reason. If The Pleasure Practice LLC determines that coaching is not appropriate or effective for my needs, Dr. Nicole may recommend other resources or referrals.

By signing below, I confirm that I have read and understand the information provided in this consent form and the coaching terms. I agree to participate in pleasure-based coaching with The Pleasure Practice LLC.

I would like to receive Dr. Nicole's Educational Newsletter

Keep me updated on Dr. Nicole's Chicagoland events

First and Last Name:

Signature

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Date

Month

Day

Year

Thank you for providing your information. Dr. Nicole will explore your responses these questions during your first session. Please reach out should you have any questions.