| Name: | |
| Email: | |
| Phone Day: | |
| Phone Evening: | |
| City: | |
| State: | |
| Time Zone: | |
| Sexual Concern Areas: | (check all that apply) |
Low or No Sexual Arousal/Desire | Sexual Addiction |
No Interest In Sex | Gender Identity Issue |
Difficulty Achieving Orgasms | Sexual Orientation Confusion |
Difficulty Achieving or Maintaining Erections | Sexual Abuse |
Difficulty with Ejaculation and/or Timing | Gay/Lesbian Sex |
Painful Intercourse or Vaginal Penetration | Other |
Unable to Penetrate Vagina or Fear of Penetration | |
| Best Time For 1 Hour Consultation: | AM (9-11)
PM (12-5)
PM (6-8) |
| Best Day of Week: | |
| (first choice) | |
| (second choice): | |
If you have not heard from me within 48 hours call 301-520-3896.
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