Therapy sessions for sexual problems

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

How long have you been suffering from this sexual problem?
less than a year 1-2 years 2-5 years 5-10 years Over 10 years

Is there any particular time when you feel that this problem is worse?
Yes No

If yes to above please give details


Is there any particular situation that makes you your sex problem worse?
Yes No

If yes to above please give details


Are there any times when you don't have this problem?
Occassionally rarely Never

Do you suffer from any allergies
Yes No

Are you taking any mind altering medication?
Yes No

Please tell me in your own words and as much detail as possible about your sexual problem. Including anything you may think is relevant no matter how silly it may sound