New Client Form - Partnership

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 sexual health or relationships?

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

Emergency Contact

Emergency contact name and relationship to you

Phone

Pleasure Practice

What would you like to learn and how would you like to grow in your relationship? What strengths do you want to build upon together?

What would a world of pleasurable sex and relating look like for you personally? What about in your relationship?

How do you navigate conflict in your relationship? What have you found to be helpful and unhelpful?

What are some practices that bring you closer together and bring pleasure into your relationship?

How would you describe your commitment to your partner(s) and your relationship as a whole?

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

Is there any additional information you would like to share that you believe is relevant to our work?

Payment Details

Before submitting this form, please confirm the following:

Consent

The Process

Dr. Nicole provides education and experiential guidance designed to support your relationship to pleasure and embodiment. Engagement in services is a collaborative process that requires a significant commitment of time and energy. This process 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 your work together. This includes reflecting on the progress of your relationship to pleasure, offering feedback around what is and is not working, what you would like more of, and any concerns you may have about your sessions. At times, this may involve moving outside your comfort zone, which can lead to deeper awareness and greater connection.

This work 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 work relationship at any time for any reason. If The Pleasure Practice LLC determines that this work is not appropriate or effective for my needs, Dr. Nicole may recommend other resources or referrals.

I understand and agree to the fee structure, scheduling arrangements, and that payment is due at the time of booking. I will make payments as agreed upon and adhere to the cancellation policy of 48 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.

By singing below, I confirm that I have read and understand the information provided in this consent form and the Pleasure Practice, LLC terms.

I would like to receive Dr. Nicole's Pleasure Activist 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. We will explore your responses these questions during your first session. Please reach out should you have any questions.