Tantra, Intimacy & Asperger's Syndrome Project
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Confidential Appointment Request Form

Please copy the questions below into the body of an email, answer them and send to Waihili@gmail.com. I will then contact you to arrange an initial conversation and/or book a first appointment.

Thank you!

Date

First Name
Last Name
Birth Date
Age

Gender Identity (circle one):
Male
Female
Other (please specify)

Address
City
State
Zip
Phone
Email

Occupation

Relationship Status:

If in a commited relationship, how long?

Is your (primary) partner supportive of you seeking counseling?

How do you define your sexual identity and choice of partners?

Do you have children?
How many?
Ages

Medical History
Are you currently under medical care? If yes, please indicate reason:

Do you take any prescription medications? If yes, what are they and what are they for?

Other significant medical history:


Counseling History
Are you currently under the care of a counselor and/or therapist, LMFT, psychologist or psychiatrist?

When was your last appointment?

If you answered yes to either of the above, please indicate the name and location of your current or former therapist:

Please tell me why you are seeking short term, sexological counseling and/or education?

Is there anything else you feel that is important for me to know?

Please note: a confidential sex history will be taken
on or before the first appointment.
This history can be filled out online.
The URL will be provided upon your request.
You will also receive a disclosure form at the first appointment.

Supporting Sexual Enrichment
for Neurodiverse Lovers