We're excited to meet you!

Your consultation will be with either Jess Seitz or a Pain-Free Intimacy team member who has also personally experienced vaginismus and who knows this program fairly well.

During our consult call, You'll share your story more and then I'll share details of the vaginismus program we offer (including the various price points and options). We'll then see if this program a good fit for you. There is no pressure to sign-up during our call and the goal of this is to be encouraging and supportive! But filling out this form is helpful for us to learn more about your journey.

First Name *

Last Name *

Maiden Name

Email *

Phone *

Date of birth *

Country *

Country

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City *

State

Relationship Status *

Married
Single
Dating
Engaged
Bi/Lesbian
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If married, how long have you been married?

Partner's Name (if applicable)

Where did you hear about Pain-Free Intimacy? *

Instagram
Facebook
Google search
Reddit
Tiktok
Podcast
Pelvic Floor Therapist
Counselor/therapist
Friend/family member
YouTube
Other
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What has worked? *

What hasn't worked? *

What have been your barriers to success? *

Just diagnosed

Stuck on a dilator size

Pain

Anxiety or fear

No time to spend on dilators

Cost of treatments

Can't transition dilator to PIV

I have no idea what to do

What are your symptoms? (Check all that apply) *

Unable to have penetrative sex

Able to have penetrative sex but very painful

Pain with insertion above a 7 out of 10 in pain

Pain with insertion between 4-7 out of 10 in pain

Pain with insertion 1-3 out of 10 in pain

Experience a "wall" when trying to insert

Burning/stinging/tearing sensation

Aching, deep pain

Unable to insert tampons

Unable to insert fingers

Unable to insert a speculum / OBGYN exam

Little to no sexual desire

Unable or extremely difficult to orgasm

Which of these are most important to you in your healing journey?

Aimed at enjoying penetrative sex

Aimed at access to health (gynecologist, tampons, etc)

My partner is included

Biblically based

Mind-Body Connection (targets nervous system)

Dilator protocol

Designed for singles

Exercises and stretches

Psychological and cognitive aspects

Desire/arousal/orgasms

Addresses purity culture

Do you have or have experienced any of the below?

PCOS

Endometriosis

Painful Bladder Syndrome (Cystitis)

Lichen Sclerosus

Vulvodynia/Vestibulodynia

Menopause

Generalized Anxiety Disorder

Temporomandibular Joint Pain (TMJ)

Medical trauma (traumatic catheterization, vaginal delivery, C-section, chronic UTIs, injuries to your pelvic/pubic area)

Sexual abuse or sexual trauma

Other (explain below)

Anything else I should know?

If this program is a good fit, I'm willing to invest financially to get the results I'm looking for

yes

If this program is a good fit, I'm willing to invest my time to get the results I'm looking for

yes

Do you agree to check your email spam/junk folder for this confirmation email with the zoom meeting link

Yes! I'll check my spam/junk folder!

Did someone refer you?

Look forward to meeting with you soon!