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Personal Info
Preference For Day And Time Of The Appointment:
(Month/Day/Year)
Your Name:
Your User Name:
Your Email Address:
In What City and State Do You Reside?
Your Physical Description:
How did you hear about me?
What is your current level of experience?
Novice | 5-10 Sessions | Advanced
Why do you wish to session
with or serve me in particular?
Do you have special skills you would like to mention or offer?
Do you have any expectations?
Describe your primary interests in BDSM:
Describe your favorite fantasy:
Describe the kind of session you would like to have with me:
Do you have special requests regarding equipment or fetish attire?
What is your philosophy or opinion about BDSM?
Please select any of the following that apply:
You are more responsive to a Mistress who has a demeanor that is:
Friendly and Conversational
Forceful and Strict
Compassionate yet Firm
Totally Condescending
Abusive and Dismissive
Sensual and Seductive
Session Dynamic:
Seduced/Teased
Intense/ Heavy
Surprised
Forced
Natural
Torture
You would classify yourself as a:
Submissive
Bottom
Masochist
Slave
Slut/Bitch
Victim
Patient
Other (Please Explain):
If you classify yourself as having a submissive, masochistic, slave, bottom mentality,
how long have you felt this way?
Do you know when your feelings originated?
What are your preferred pain level or sensation limits?
Not Sure
Light
Moderate
Heavy
Extreme
Activities & Preferences
Bondage, Restraint, Encasement
Bondage Types:
Vulnerable Bondage
Symbolic Bondage
Moderate Bondage
Predicament Bondage
Strenuous
Inescapable
Immovable
Hoods :
Latex
Leather
Cloth
Gags:
Ball
Ring
Inflatable
Cock-gag
Piss-gag
Mummification:
Partial
Complete
Bondage Materials:
Rope
Tape
Saran
Ace Bandage
Vet Wrap
Handcuffs
Leather Restraints
Chain
Collars and Leashes
Blindfolds
Suspension:
Partial
Full
Other Types Of Bondage:
Full Body Bondage
Cage
Cock and Ball Bondage
Sensory Deprivation
Sensory Overload
Vacuum Bed
Solitary Confinement
Slings
Chastity
Isolation
Abandonment
Corporal Punishment
Whipping-mild
Whipping-moderate
Whipping-heavy
Whips
Floggers
Riding Crops
Canes
Single-tail
Spanking:
Traditional OTK
Soothing and Sensual
Corrective
Rhythmic
Mild
Moderate
Heavy
Spanking Implements:
Bare Hand
Hairbrush
Paddles
Slapper
Straps
Shoes/English Slipper
Feminization/Cross-Dressing
Light/Partial/Full Transformation
Sensual
Teasing as a form of humiliation
Under Clothes
Corset Training
Outings or shopping trips
Fantasy/ Psychodrama
Mistress/slave
Strict Discipline
Domestic
Sissy-Slut
Maid Service
Office
Classroom
Baby-sitter
Mommy
Auntie
Governess
Interrogation
Racial Taboo's
Nazi Fantasy
Black Plantation Slave
Equestrian/Pony Training
Dog/Puppy Training
Inanimate Object
Physical Domination
Mind Fuck
Nurse-Medical
Vampire
Cat Woman
Age Regression
Kidnap-Captive-Abduction
Castration (Fantasy ONLY)
Objectification
Other:
Stimulus
Spitting
Kicking
Hair Pulling
Face Slapping
Teasing
Adam & Steve Scenes
Dildo Worship
Slut Training
Strap-on Play
Vibrating Toys
Cock and Ball Play
Cock and Ball Torture
Trampling
Smothering
Foot & Leg Worship
High Heel or Boot Worship
Golden Showers:
Sensual
As a form of Humiliation
Reward
Ingestion
Enema Sports
Nipple Play
Nipple Torture
Electrical Play
Electrical Torture
Water Torture
Breath Play:
Smothering
Choking
Strangulation
Knife Play
Burning
Biting
Scratching
Implements
Candle wax
Clothes pins/clamps
Weights
Forks
Scalpels
Needles
Surgical staples
Saline injection
Catheter
Sounds :
Vibrating Sounds
Urethra Stretching
Humiliation
Humiliating acts
Humiliating talk
Verbal abuse - mild
Verbal abuse heavy
Exhibitionism
Shaming
Food mortification
Force feeding
Forced masturbation
Forced ejaculation with penalties
Ashtray
Reduction
What forms of humiliation appeal to you specifically?
Mistress Attire
Leather
Latex
PVC
Corset
Stockings & Garters
Nylons
Panty
Lingerie
Business Suit
Stiletto Heels
with platform
without platform
no preference
Simple Black Dress
Formal Wear
Fetish
Latex
Leather
PVC
Gloves
Body Parts
Foot & Leg
Heels- Shoes
Boots
Smoking
Other:
Limits
NO Pain
NO Humiliation or Degradation
NO Breaking of the Skin
Degree of Marking:
None
Light
Lingering
Permanent
I mark easily
Describe any and all limits that you have:
Health Issues
Contact lenses or glasses
Bad back
Joint problems
Neck problems
High blood pressure
Low blood pressure
Low blood sugar
Bad Knees
Hemorrhoids
Heart Problems
Diabetic
Asthma
Injury:
Have you ever had what you would consider to
be a Traumatic Experience? Please explain:
Do you have any phobias? Please explain:
Are you taking any prescribed medications?
Are you taking Viagra or other stimulants?
Do you have any known sexually transmitted
diseases (I am tested regularly and suggest that
you do the same)? If so, please list them:
When was the last time you were tested for
sexually transmitted diseases, and what were the
results?
Contact in case of an emergency?
Additional Comments:
Please note:
I will not see anyone who is under the influence of alcohol or illegal drugs.
If you arrive under the influence I will not conduct the session and I will dismiss you. You will also be charged a walk fee as a result for my time and preparation. Showing up for a session under the influence of alcohol or illegal drugs will also result in banishment.
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