Personal Assesment Form | Mare Simone

Private Session

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Personal Assesment Form

Sexploration Assessment

I invite you to join me on a journey to juice up your life! This work is deep and personal so I like to know you intimately, enough to best support your needs and help you achieve your greatest goals! Please only fill out what you are comfortable sharing. Speak with you soon!

Name*
First
Name
Last (optional)
Gender*
- Male
- Female
Birthdate*
Month
Day
Year
Best Email Address*
Best Phone Number
Occupation*
Are you interested in:
- Private Sessions
- Workshops
Are you in a relationship?
- Yes
- No
If yes, is your partner joining you? (If so, please have them fill out a separate form)

Relationship dynamics. Challenges
Briefly describe your relationship (or past relationships) dynamics?
Desires. Challenges or Difficulties:*
What do you desire? Are there any challenges you struggle with this pursuit?
What is your desired outcome from our work together?*
Have you any background in personal awareness, spiritual practices like Tantra, Yoga? Martial Arts, dance, massage etc?
How did you find me?*
On a scale of 1 - 10 how ready are you in resolving your issues?*
Best email address
1 as the least ready. 10 being the most ready and eager. What will that do for you?
What postal zip code do you live in?
Or suggest other locations where you'd like to meet, including LA, CA, if you are open to traveling to me for in-person sessions.
Thank you for your time. Are there any Comments or Questions you'd like to ask?
By registering and entering your email address & phone number you will agree to be contacted both by email & phone. Message and data rates apply.
Email
This field is for validation purposes and should be left unchanged.