Personal Info

Your Name:

Your Email Address:

Gender:
Male

Age:

Telephone Number I Can Reach You At: (No spaces or dashes)

In What City and State Do You Reside?

What is your current level of experience?

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/X-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

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:

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

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?

Please list prescribed medications you are taking.

Are you taking Viagra or other stimulants?

List Viagra or other stimulants that you are taking, if any.

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? Please list someone you trust and a phone #

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.