Thank you for contacting the Conscious Intimacy Center.

This short form helps us understand what kind of support you are looking for and identify the most appropriate next step. It is not a clinical assessment, and you do not need to describe your complete personal history.

Please avoid including highly sensitive information unless it is essential for us to understand your request. More detailed information can be shared securely after your first appointment has been confirmed.

Your Contact Details

Full name

Email address

Telephone number (optional)

Preferred contact method

Country or place of residence

Preferred language

Time zone

What Are You Looking For?

Which service are you interested in?

Are you contacting us for:

Do you already have a therapist in mind?

What would you like support with?

Share only a brief description of what you are looking for. Please do not include diagnoses, medication lists or detailed medical, trauma or sexual histories here.

What would you most like to be different as a result of this process?

Practical Preferences

Would you prefer:

What type of appointment are you looking for?

When would you ideally like to begin?

Matching and Accessibility

Is there anything important for us to consider when helping you choose a therapist?

If you need a practical adjustment for a conversation or session, briefly describe it without diagnoses or medical details.

How did you hear about the Conscious Intimacy Center?

Privacy and Communication

By submitting this form, you confirm that you have read the basic information about how the Conscious Intimacy Center will use your personal data to respond to your enquiry and help you access the most appropriate service.

I have read the Privacy Notice. Read the full Privacy Policy I agree to be contacted through WhatsApp regarding this enquiry. I would like to receive occasional information about CIC workshops, programs, retreats and events.