Jamie S. Weiss, LMFT, CCST, Transgender Care Specialist Weiss Psychotherapy Group,LLC 398 Camino Gardens Blvd, #201, Boca Raton, Florida 33432 561-213-6327 [email protected]
Brief Sexual History- Male
Personal Data
Name ______
Phone______Okay to call/text? _____
Address______
Email______Okay to email?____
Relationship status______
______
Present Sexual Orientation______
Gender Assigned at birth______
Preferred Gender Identity______
Present living situation______
Sexual History Age of first sexual feeling_____ Age of first wet dream_____ Age of first masturbation_____ Age of first sexual attraction_____ Age of first date: _____ Age of sexual intercourse_____ Age of first orgasm_____ Date of last orgasm_____
Please write brief answers to these questions
1) What childhood message about sex/sexuality did you receive growing up?
2) What brought you into therapy? What current concerns do you have about your sexuality?
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Jamie S. Weiss, LMFT, CCST, Transgender Care Specialist Weiss Psychotherapy Group,LLC 398 Camino Gardens Blvd, #201, Boca Raton, Florida 33432 561-213-6327 [email protected]
3) What concerns do you have about being male?
4) What has been your experiences with orgasm? Alone? With a partner?
5) What has been your experience with masturbation?
6) What is your present pattern for and frequency of masturbation?
7) How did you feel about your body in childhood? As a young adult? Now?
8) Describe the history of your sexual relationships. (The number of partners, what sexual activities you have experienced, and the issues and conflicts that have emerged for you in intimate relationships) Use additional paper if needed.
9) Describe any issues you may have about having sexual contact with your present or a future sexual partner(s).
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Jamie S. Weiss, LMFT, CCST, Transgender Care Specialist Weiss Psychotherapy Group,LLC 398 Camino Gardens Blvd, #201, Boca Raton, Florida 33432 561-213-6327 [email protected]
10) Describe your current sexual interactions, such as intercourse or masturbation, what arouses you, your present pattern for sexual pleasure, frequency of sexual interactions, your current number of partners, etc.
11) How often do you think about sex or have the desire for sex? (daily, several times per day, week, monthly, etc.) 12) 13) Which of the following arouses you? ___erotic/pornographic magazines ___erotic/pornographic videos ___romance novels___ erotic literature ___phone sex lines ___online sex chats ___internet sex (live) ___S &M play ___prostitutes ___cross-dressing ___swinging ___voyeurism ___ fantasy during masturbation ___vulgar sex talk ___other______
14) Are you open to learning bodywork such as masturbation or other sexual enhancement techniques?______
15) Are you open or desire to work with a sexual surrogate?______
16) Do you have any medical conditions that may affect your sexuality? (i.e. diabetes, heart disease, etc.) ______
17) Are you currently prescribed and compliant with medication?______
18) 19) What are your long term sexual goals?______
20) What is your goal for sex therapy?______
21) Do you agree to making changes and following through with assignments?______
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Jamie S. Weiss, LMFT, CCST, Transgender Care Specialist Weiss Psychotherapy Group,LLC 398 Camino Gardens Blvd, #201, Boca Raton, Florida 33432 561-213-6327 [email protected]
22) Please describe any other information about yourself that may be helpful in working toward your sex therapy goals______
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