Sexuality Therapeutic Questionnaire

Sexuality Therapeutic Questionnaire

Providence Psychotherapy, LLC

Sexuality is a fundamental aspect of our lives affecting our mind, body, emotions, identity, and relationships. Research shows when people can express themselves sexually they feel more vital and alive. Increasing sexual awareness, knowledge and functioning can lead to an increase in fulfillment, relational connection and sense of self.

Presenting Issue

1. Describe the issues you are having with sexuality?

1. When was the onset of the issue, how often and when does it occur?

1. Are there times when the issue does not occur? If so when?

1. What is your understanding of the issue?

1. What have you tried to resolve the problem? Have you experienced any percentage of success?

1. What do you expect to achieve by coming to therapy?

1. Has a medical doctor evaluated you for this problem? If so what was the finding?

History

1. Have you experienced physical, emotional, spiritual or sexual abuse in the past? If so, describe.

1. List 3-5 words to describe your first and past sexual experiences.

1. Did your parents talk to you about sex? Yes or No

What messages did you get from your parents about sex and sexuality?

1. Have you had any negative sexual experiences? Yes or No

If so describe.

Additional Assessment Questions

1. Do you use contraceptives, hormones, or use SDT/pregnancy prevention methods. Yes or No If so what?
2. Do you have pain with sex or masturbation? Yes or No If so describe.

1. Are you in a committed relationship? Yes or No
2. Have you discussed your sexual history with your partner? Yes or No
3. How did you meet and what attracted you to your partner?

1. Do you have children? Yes or No Were they planned? Yes or No
2. Has your sexuality changed since having children? If so how?

1. Do you feel able to express yourself sexually or emotionally to your partner and have it well received? Sexually: Yes or No Emotionally: Yes or No

1. Describe a typical sexual interaction with your partner.

1. Describe your ideal sexual interaction with your partner.

1. How do you feel about your body? About your partners body?

1. How do you think your partner feels about your body?

1. What is your goal(s) for having sex?

1. What meaning does sex have for you? Do you have any religious or spiritual beliefs about sex?

1. Do you use alcohol, substances, or take medication? If so, list what kind, amount, and frequency.

1. How often do you exercise?

1. Do you have any difficulty with sleeping? Yes or No How many hours do you sleep at night?

1. Do you have any physical or mental health problems or conditions? If so, describe.

1. List hobbies and interests you engage in to relax and have fun.

1. What do you and your partner do together for fun? How often?

Desire, Arousal, Orgasm Functioning Questions

1. How frequently do you have sex? Masturbate?

1. How frequently do you feel like having sex or masturbating?

1. How often would you like to have sex or masturbate?

1. Do you initiate sex? Yes or No Does your partner? Yes or No
2. How do you feel when you or your partner initiates sex?

1. What turns you on leading to desire for sex?

1. What turns you off and decreases your desire for sex?

1. What gets in the way of having sex?

1. When (times of day, circumstances) do you usually desire sex?

1. Do you have difficulty getting or staying aroused with stimulation?

1. Does arousal build with continued stimulation? Yes or No

1. What kind of stimulation leads to initial or maintained arousal?

1. Which parts of your body feel positive or negative when touched?

1. Do you have any difficulty reaching orgasm? Yes or No

1. How do you feel about yourself and your partner after sex?

Client Input

List any additional information not covered on the questionnaire that you would like to share that you think would be beneficial for your treatment and outcome or that you would like the therapist to know.