This is the old school version you must copy and paste into your email before adding your answers.

This remains just in case the new fill in form application fails to work for any reason.

Portia’s BDSM Application

(for prodomme session )

General Application 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, but indicate what question you are answering please.

!!!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 __________________________________

Where did you learn about my services? (specific website?) ____________________________________________________________________________

Are you? ______ male _____female ______Couple

If couple, name of second party__________________________________________________________

Relationship to other party? _____married ______dating ______play partner only

_____________other (please explain briefly)

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 (ringworm, psoriasis, poison ivy, poison oak, sumac, open sores, blisters, etc…)

- ___Mobility issues (wheelchair 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 mark the items below that interest you or that you would like to try with an “X”

    1. Blindfolds

    2. Bondage

    3. Breast/Nipple Torture (clamps, electro, needles)

    4. Caning

    5. Chastity Devices (you supply)

    6. Cling Film/Plastic Wrap

    7. CBT (cock & ball torture)/Ball Busting

If yes, do you prefer crushing/smashing, impact play, stretching/weights, squeezing, punching, kicking, electro, or something else?

Which of your CBT selections have you actually tried before?

    1. Collar & Leash

    2. Confinement

    3. Cross Dressing

    4. Shaving (you)

    5. Discipline

    6. Dr/Nurse medical play

    7. Electro play (electric stimulation/e-stim/tens/violet wand)

    8. Exhibition (someone to watch, no public outings due to confidentiality issues)

    9. Feathers/Light Touch Tickling

    10. Flogging

    11. Foot Fetish

If yes, in what ways do you like to express your fetish?

    1. Hair Pulling

    2. Handcuffs/Shackles

    3. High Heels (for you to wear, sir)

    4. Leather Hoods/Masks

    5. Humiliation

    6. Masturbation (not that I will let you, or perhaps you need to do it in front of someone to learn your lesson)

    7. Nylons/Pantyhose (for YOU to wear, sir)

    8. OTK (over the knee spanking)

    9. Paddling

    10. Pinching

    11. Sensory Play (this can be pain or pleasure using your various senses)

    12. Shoe/Boot Fetish

If yes, how do you like to express your fetish? (kissing shoes, touching shoes, etc)

    1. Tickling (light touch or the kind like when you were a child)

    2. Vacuum Bed/Complete Immobilization

    3. Vibrators (I don’t always use items in ways you would expect so you might elaborate a bit if you check this one)

    4. Whips/Crops/Sjamboks/Quirts/Martinets

Please explain any other additional thoughts, ideas or items you wish for me to consider doing or using during a session:

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/hour

90 mins $375, 2 hours $500 and so on

Longer sessions available upon request

*Please allow up to 3 days for a response. You will be contacted by the email you provided.