Form Instructions  --  Please copy & paste these questions to your email & respond to ALL questions  --  then email it back to me for my consideration --  if you cannot follow directions, you will not get an appointment.  

If you can’t copy and paste, then just send me just your answers without the form.

!!!Confidentiality:   All identity information is strictly confidential and for my eyes only!!!!  Please be honest and forthcoming with your answers.  The information below will help me identify your experience level, interests and allow me to tailor a session specifically for you.  I like to know we are on the same page before we discuss ANY appointment times.  I take confidentiality VERY serious (both yours and mine).

Personal Information:

Name (First & Last, this info goes nowhere so please be honest) __________________________________________________________________________

Email (where you may be reached, don’t say “this one” and make me go hunting to match it up, that only irritates me) ___________________________________________________________________________

City and State ________________________________________________________________

Phone (____)-_____-________  (I don’t make a habit of calling unless absolutely necessary & you’ve said it was okay, so no worries)

Okay to call?  Yes ___or No___                 If Yes, do you require calls from me within specific hours?  Please indicate the time period it is ok to call __________________________________

How did you learn about my services?  _____________________________________________________________________________

Are you?  ______ male     _____female

Do you have any of the following medical issues? (please X on the line if yes)   Your safety is important to me, so please be honest.

-          ___Post Traumatic Stress Disorder          - ___History of heart disease

-          ___Depression                                           - ___History of heart attack, stroke or T.I.A.

-          ___Anxiety                                                  - ___Blood clots or history of

-          ___Do you have a pacemaker                    -___Bruise easily

-          ___Skin conditions (ring worm, psoriasis, poise ivy, poise oak, sumac, open sores, blisters,  etc…)

-          ___Mobility issues (wheel chair bound, unable to climb stairs, limited joint mobility, etc…)

-          ___Are you on any medications (include any that may make you bruise or mark more easily, any blood thinner medications, etc)

Please explain any health items that you checked above (your safety is important to me): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What is your experience level with B.D.S.M? (check one)

Newbie                ___        Some Experience ___    Very Experienced ___

Have you visited a professional domme, mistress or any BDSM worker before (no, a call girl or hooker does not count and they are not the same thing)?

_____ yes    _____no

Can you have marks? (be realistic, canes, whips and floggers will usually leave marks)

No___        Yes, Please___          Only if the disappear quickly___    A few hidden___

Do you mark easily?  ____ yes    _____no

Please indicate the areas that you are interested in and/or  would like to try in a session with me.

Please mark (yes, no, or maybe)   

Blindfolds -

Bondage -

Breast/ Nipple Torture -

Caning -

Chastity Devices (you supply) -

Cling Film / Plastic Wrap -

Cock & Ball Torture (clamps, weights, electrical, ball busting, slapping, etc) -

Collar & Leash -

Confinement (cage or box)-

Cross Dressing (make over, dress up) -

Depilation / Shaving -

Discipline -

Role Play (Dr/Nurse, Boss/Emp, Teacher/Student, Nun/Sinner, Cop/Perp, etc)-

Electro-play (estim/tens unit)-

Exhibitionism -

Feathers/Light touch/Tickling -

Flogging -

Foot Fetish -

Hair Pulling -

Handcuffs / Shackles -

High Heels (for your feet, sir) -

Leather Hoods -

Humiliation -

Masturbation (you pal, not me)-

Nylons -(for your legs, sir)

OTK (over my knee, for spanking or punishment) -

Paddling -

Pinching -

St. Andrews Cross (being bound to)-

Sensory Deprivation/Sensory Play (cut off sight and sound, different items used to tease your senses like hot wax, ice, crops, light touch, feathers, vampire gloves, etc)-

Shoe / Boot Fetish -

Trampling or C&B Trampling -

Vacuum- Bed (immobilization) -

Vibrators -

Whips -

Other -

Please explain any additional thoughts or ideas you wish me to consider below:

Please describe what you envision a session with me to be like or consist of: (answer this in detail, I ask it for good reason!!)


Tribute 250/hr
90 min & 2hr appts available
** 2 domme appts by special request only (tribute 500/hr & up & may vary)

SelectionFile type iconFile nameDescriptionSizeRevisionTimeUser
  Oct 29, 2013, 6:22 PM Portia SpanksKC