Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Contact Method: *

We will email you initially from californiarelationshipcenters@gmail.com

Only Email

Phone & Email

No preference

May we leave a voice message and may we state where we are calling from? *

We Value Your Privacy

Yes leave a VM but please do not state your Center's name and just say "we are returning your call..."

Yes, call and say where you are calling from if I answer, but do not leave a VM.

Yes, to both leaving a VM and saying your Center's name.

What are your pronouns? *

She / Her / Hers

They / Them / Theirs

He / Him / His

Other

What are your partner's pronouns? *

They / Them / Theirs

She / Her / Hers

He / Him / His

N/A- I do not have a partner or am not looking for partner-based services

I am seeking: *

[Select all that apply]

Individual Therapy & Counseling

Couples / Partner Therapy & Counseling

Sex Therapy & Counseling

Pre-Marital / Commitment Counseling

Relationship & Sexuality Coaching

Sex & Intimacy Therapy Needs:

Please choose any relevant areas of support you seek. If needed, you can provide more details in the extra info section below. (Select all that apply)

Sex & Intimacy Therapy- General

Sex & Intimacy Therapy (with my partner)

Sex Therapy (just for me)

LGBTQ+ Sex Therapy (Individual)

LGBTQ+ Sex Therapy (Couples/Partners)

Libido Discrepancy Between Partners

Lack of Libido / Desire

Painful Sex

Erectile or Climax Issues (all genders)

Somatic-based Sex Therapy (Individual)

Sexual Trauma

Problematic Sexual Behaviors

Perimenopause/Menopause & Sexuality

Private Intimacy Intensive

Relationship & Couples Therapy Needs:

Please choose any relevant areas of support you seek. If needed, you can provide more details in the extra info section below. (Select all that apply)

Couples Therapy- General

Marriage & Couples Counseling

LGBTQ+ Couples/Partners Therapy

Pre-Marital Counseling

Attachment-Based Couples Therapy

Infidelity Repair

Divorce or Breakup Support

Relationship Coaching

Polyamory & Non-Monogamy Support

LGBTQ+ Couples Therapy

Co-parenting Support

Private Relationship Intensive

Individual Therapy & Coaching Needs:

Please choose any relevant areas of support you seek. If needed, you can provide more details in the extra info section below. (Select all that apply)

Individual Therapy (Adults)

LGBTQ+ Individual Therapy

Women's Therapy

Attachment-Based Individual Therapy

Divorce or Breakup Support (Individual)

Relationship Coaching (Individual)

Polyamory & Non-Monogamy Support (Individual)

Parenting Support (Individual)

Private Intensive

Life & Goal Coaching

Men's Therapy

Attachment-Based Therapy (Individual)

General Psychotherapy

Trauma Therapy & Needs:

Please choose any relevant areas of support you seek. If needed, you can provide more details in the extra info section below. (Select all that apply)

Individual Trauma Therapy -General (Adults)

Attachment Trauma (Individual) Therapy

Somatic Experiencing Trauma Modality

EMDR & Trauma Therapy

Grief Therapy

Other Specialized Services:

Please choose any relevant areas of support you seek. If needed, you can provide more details in the extra info section below. (Select all that apply)

Executive /Business Partnership Therapy

Are You Interested in an Intensive or Retreat? *

We offer private customized intensives (online and in person at select locations) designed for those seeking deep transformation on a faster timeline.

Yes

Not at this time

I am open to an intensive or on-going sessions

Provider Preferences: Do you have any preferences for your provider? *

We strive to connect you with the best fit for your needs and prioritize emotional safety, especially for underrepresented communities. If you have any preferences, please let us know.

No preference/ Best fit

Female provider

Male provide

Non-binary / Trans provider

LGBTQ+ provider

Kink affirming provider

Polyam / ENM / CNM affirming provider

BIPoC provider

No preference

Would you like online sessions? *

We offer secure, private online sessions

Yes

No

No Preference

Would you like in-person sessions? *

We offer in-person sessions in select locations

Yes

No

No Preference

Would you like phone sessions? *

We offer secure, private phone sessions

Yes

No

No Preference

Payment & Insurance ✔ I understand that [San Francisco Intimacy & Sex Therapy Center] does not bill insurance directly. *

I understand that my provider will not accept insurance and that I am responsible for full payment at the time of service. I will check with my insurance provider regarding Super Bill reimbursement.

I acknowledge this (Required to proceed)

Do you plan to submit for out-of-network reimbursement from your insurance? *

Insurance Notice: SFISTC does not contract with insurance companies. However, our licensed and pre-licensed therapists may provide a Super Bill, which may allow for partial reimbursement, depending on your insurance provider. For details, please review our Insurance FAQ.

Yes

No

Not sure

Final Consent: "I understand that this form is not a guarantee of services and that my information will be reviewed for provider matching. I acknowledge that [San Francisco Intimacy & Sex Therapy Center] is not a crisis service."

I understand. and agree (Required to submit form)