BDSM Education- Original Negotiation Form

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I am the creator of the original D/s (BDSM) negotiation form.  I first wrote the negotiation form in the 70's and published the negotiation form back in 1982/83.

A bit of history- I created the negotiation form as a way to get those about to play with me to do some soul searching and thinking about what they were about to get into.  It made it easier for me to get information about their wants, expectations, and any health issues etc. and having it all on paper made it easier than trying to remember it all when planning to play with them.  It also gave them information about me.  I stupidly used my negotiation form with a woman (that happened to be a publisher) for use between us for play.  It appears her and her partner plagiarized my work as it ended up in their BDSM books with no credit to me.  It was not theirs and to steal my work, knowledge, and effort is not okay.

I have given only a couple of web sites permission to display my copyrighted works and they have a my permission notice listed with a link to this site.  Unfortunately people continue to have my work on their web site and/or in books without my consent and this continues to be an issue.  Hopefully web sites and publishers will do the correct thing so my negotiation form can still be a resource for those into or wanting to explore BDSM. 

So if you see my negotiation form (or part of it) on another BDSM site or the Internet without credit to me, please let us know. They are violating copyright laws.  

Interested in learning more about copyrights?  For your convenience here are a few links: 
http://whatiscopyright.org/   http://www.templetons.com/brad/copymyths.html

My negotiation form has grown since it's first publication, over the years it has grown to include things that were not around or of concern to us back in the late 70's and early 80's.  The most current version and most current layout is found in my book Top to Bottom A BDSM Perspective.  I hope you find this form helpful.  

I created this form originally for me, the Domme to gain insight about the sub/bottom/slave and to force the sub/bottom/slave to do some real soul searching about themselves and BDSM.  
Since most feel BDSM is an exchange of power, you will find sections for both the sub/bottom/slave and the Dom/me to fill out.

>Negotiation Long Form 

Not all applies to our scenes, do answer the questions honestly and openly, for this will help me in making your experience wonderful.  The answers I am willing to share at this time are found under Dom/me, your answers should be under sub and all sub questions should be completed.

 

1. People           
  Who will take part?          
  Who will watch?          
  Note: Unless prior negotiation is done, the session will involve only those people specifically named above.          
  Will any permanent record be made of the session? Yes No      
  Will any photographs be taken? Yes No      
  Will any video be taken? Yes No      
  Will any audiotapes be made? Yes No      
  Would you like a future session to have photos taken? Yes No      
  Would you like a future session to have video taken? Yes No      
             
  Do you currently have any involvement with law enforcement agencies?
If no, you are obligated to let me know if you become involved with any law enforcement agency.
e.g.: Are you a police officer in any aspect? Are you on parole?
         
  Dom/me Yes No      
  sub Yes No      
  If yes explain-           
             
2. Roles          
  Who will be Dominant?          
  Who will be submissive?          
  Type of scene: Dom/me Dom/me sub sub  
  Mistress/Slave Yes No Yes No  
  Captor/Captive Yes No Yes No  
  Servant/Butler Yes No Yes No  
  Age play Yes No Yes No  
  Cross-dressing/gender play Yes No Yes No  
  Animal play Yes No Yes No  
  Any chance of switching roles? Yes No Yes No  
  Others? 
Explain:
         
             
3. Place          
  Location:          
  Who will ensure privacy? Dom/me sub Both Others  
  Will play take place in an isolated area such as a farmhouse or other location? Yes No Maybe    
  Will play take place at a play party/dungeon? Yes No Maybe    
  Will play take place outdoors? Yes No Maybe    
  Dom/me are you currently certified in First Aid? Yes No      
  submissive are you currently certified in First Aid? Yes No      
  Dom/me are you currently certified in CPR? Yes No      
  submissive are you currently certified in CPR? Yes No      
  First Aid kit to be on hand?
If yes, who will bring it?
Yes No      
  Flash Light to be on hand?
If yes, who will bring it?
Yes No      
  Blackout lights to be used?
If yes, who will bring it?
Yes No      
  What precautions will be done to ensure safety for both in a medical situation?          
  Example: Panic snaps so submissive can get free if dominant becomes unconscious.
What other precautions will be used?  
List all that apply.
         
             
4. Time           
  Begin at:          
  Length of time:          
  Beginning Signal: (example some like to do a ritual or play collaring)          
  Ending Signal:          
  Who will keep track of time?          
             
5. Obedience          
  Will submissive promptly obey? Yes No Most of the time    
  May the dominant "overpower" or "force" the submissive? Yes No Would like to explore    
  Explanation:          
  Might the submissive want to verbally resist? Yes No Would like to explore    
  Explanation:          
  Might the submissive want to physically resist? Yes No Would like to explore    
  Explanation:          
  Does the submissive want to try to "turn the tables"? Yes No Would like to explore    
  Explanation:          
  Does the submissive agree to wear a collar? Yes No      
  Explanation:          
  The submissive agrees to address the dominant by the following titles: (include any others) Sir/Ma'am Master/Mistress My Lord/My Lady    
             
6A. Limits          
  Submissive's limits:          
  What is your current health condition? Poor Fair Average Good Excellent
             
  Submissive's physical/emotional/BDSM activity limits:          
  Any problem with the submissive's:     Explanations    
  Heart Yes No      
  Liver Yes No      
  Lungs Yes No      
  Neck/Back/Bones/Joints? Yes No      
  Kidneys Yes No      
  Nervous System Yes No      
  Mental Illness Yes No      
  FYI- Diabetes, Heart Disease and Asthma are three of the most common diseases that can have negative effect on play.  I need to know what can occur and we need a plan to handle these diseases in our play.          
             
  Have you, the submissive had a heart attack? Yes No      
  If yes, When?          
  What medications are you taking? List all medications (not just heart medication):  
FYI-Heart medications can alter your blood pressure and I need to know this.
         
  Are you wearing contact lenses? Yes No      
   Are you wearing dentures or any other dental appliance? Yes No      
  Do you have implants?
If yes, list them all:
Yes No      
  Do you have implanted pace maker? Yes No      
  Do you have metal implants?
If yes, where?
Yes No      
  Do you have a drug metering pump?
If yes, for what drugs?
Yes No      
  Do you have any artificial body parts?
If yes, give list
Yes No      
  Do you have a history of:          
  Seizures Yes No      
  Dizzy Spells Yes No      
  Diabetes Yes No      
  Hyperglycemia Yes No      
  Seizure disorders Yes No      
  Known brain wave abnormalities Yes No      
  High blood pressure Yes No      
  Fainting Yes No      
  Asthma Yes No      
  Heart Rhythm oddities
If yes, give explanation
Yes No      
  Do you have problems with circulation? Yes No      
  Are you subject to leg cramps or charley horses? Yes No      
  Do you have any foot problems? Yes No      
  Do you have any hearing problems? Yes No      
  Do you have an eye sight problems? Yes No      
  Do you have any old injuries that still cause discomfort? Yes No      
  Hyperventilation attacks? Yes No      
  Describe any phobias:          
  submissive's medical conditions:          
  Have you had any surgeries?
If yes, list them:
Yes No      
  Do you have any surgical implants (breast, face, etc.)?
Explanation:
Yes No      
  Do you have hemorrhoids?
If yes, do you feel this will have an effect on our play?
Yes No      
  Are you, the submissive taking:          
  Aspirin? Yes No      
  Non-steroidal, anti-inflammatory drugs? Yes No      
  Ibuprofen, Motrin, Naprosen, Aleve, Vioxx, Celebrex or other?
These can cause a person to bruise quicker/easier with less impact/force then in "normal" play.
Yes No Please list them:     
  Are you taking anti-histamines? Examples; Benadryl, Hismanal, Atarax, Actifed, and Seldane.  These can cause blood pressure changes as well as changes in equilibrium. Yes No Please list them:     
  List any other medication you, the submissive are taking:          
  Do you have any known allergies? Yes No      
  Bandage tape? Yes No      
  Nonoxynol-9 Yes No      
  Latex Yes No      
  Food allergies?
If yes, list them:
Yes No      
  Drug allergies?
If yes, list them:
Yes No      
  Any allergy to any metals?
If yes, please list the metals:
Yes No      
  Any allergy to rubbing/isopropyl alcohol? Yes No      
  Allergy to semen? Yes No      
  Allergy to any lubes?
If yes, list them:
Yes No      
  Allergy to any chemicals? Yes No      
  Allergy to any animal? Yes No      
  List any other allergies:          
  List any other medical conditions:          
             
  In case of emergency notify:  Phone#:        
  Name and phone number of the medical general practitioner you would like called in an emergency visit to the hospital.          
  What information is to be given in emergency?          
  Any possibility you are pregnant? Yes No      
             
             
6B. Limits          
  Dominant's limits.          
  What is your current health condition? Poor Fair Average Good Excellent
  Any problems with your:          
  Heart Yes No      
  Liver Yes No      
  Lungs Yes No      
  Neck/Back/Bones/Joints? Yes No      
  Kidneys Yes No      
  Nervous System Yes No      
  Mental Illness Yes No      
  Have you, the dominant had a heart attack?
If yes, when?
Yes No      
             
  What medications are you taking? List all medications (not just heart medications):  
FYI-Heart medications can alter your blood pressure and the sub needs to know this in case something happens.
         
  Are you wearing contact lenses? Yes No      
   Are you wearing dentures or any other dental appliance? Yes No      
  Do you have implants?
If yes, list them all:
Yes No      
  Do you have implanted pace maker? Yes No      
  Do you have metal implants?
If yes, where?
Yes No      
  Do you have a drug metering pump?
If yes, for what drugs?
Yes No      
  Do you have any artificial body parts?
If yes, give list:
Yes No      
  Do you have a history of:          
  Seizures Yes No      
  Dizzy Spells Yes No      
  Diabetes Yes No      
  Hyperglycemia Yes No      
  Seizure disorders Yes No      
  Known brain wave abnormalities Yes No      
  High blood pressure Yes No      
  Fainting Yes No      
  Asthma Yes No      
  Heart Rhythm oddities
If yes, give explanation:
Yes No      
  Do you have problems with circulation? Yes No      
  Are you subject to leg cramps or charley horses? Yes No      
  Do you have any foot problems? Yes No      
  Do you have any hearing problems? Yes No      
  Do you have an eye sight problems? Yes No      
  Do you have any old injuries that still cause discomfort? Yes No      
  Hyperventilation attacks? Yes No      
  Describe any phobias: Yes No      
  Dominant's medical conditions:          
  Have you had any surgeries?
If yes, list them:
Yes No      
  Do you have any surgical implants (breast, face, etc.)?
Explanation:
Yes No      
  Do you have hemorrhoids?
If yes, do you feel this will have an effect on our play?
Yes No      
  Are you, the dominant taking:          
  Aspirin? Yes No      
  Non-steroidal, anti-inflammatory drugs? Yes No      
  Ibuprofen, Motrin, Naprosen, Aleve, Vioxx, Celebrex or other?
These can cause a person to bruise quicker/easier with less impact/force then in "normal" play.  Yes Dom/me's occasional miss and hit themselves.
Yes No Please list them:     
  Are you taking anti-histamines? Examples; Benadryl, Hismanal, Atarax, Actifed, and Seldane
These can cause blood pressure changes as well as changes in equilibrium.
Yes No Please list them:     
  List any other medication you, the dominant are taking:           
  Do you have any known allergies? Yes No      
  Bandage tape? Yes No      
  Nonoxynol-9 Yes No      
  Latex Yes No      
  Food allergies?
If yes, list them:
Yes No      
  Drug allergies?
If yes, list them:
Yes No      
  Any allergy to any metals?
If yes please list the metals:
Yes No      
  Any allergy to rubbing/isopropyl alcohol? Yes No      
  Allergy to semen? Yes No      
  Allergy to any lubes?
If yes, list them:
Yes No      
  Allergy to any chemicals? Yes No      
  Allergy to any animal? Yes No      
  List any other allergies          
  List any other medical conditions          
  In case of emergency notify:          
  Name and phone number of the medical general practitioner you would like called in an emergency visit to the hospital. Phone#:        
  What information is to be given in emergency?          
  Any possibility you are pregnant? Yes No      
             
7. Sex Dom/me Dom/me submissive submissive  
  Are you female? Yes No Yes No  
  Are you male? Yes No Yes No  
   Are you a TS? Yes No Yes No  
  If yes, are you pre-op? Yes No Yes No  
  If yes, are you Post-op? Yes No Yes No  
             
  Age:          
  Marital/Relationship Status.          
  Single/Married/Civil Union/Significant Other/Domestic Partners/Legally Separated/In middle of divorce? Other?          
  Monogamous? Yes No Yes No  
  Sneaking behind partners back? Yes No Yes No  
  Poly?
If yes, Polyamory, Polyfidelity? Polysexual?
Yes No Yes No  
  Do you currently have a Body Fluid monogamy/Body Fluid bonding agreement with someone? Yes No Yes No  
  Heterosexual Yes No Yes No  
  Homosexual Yes No Yes No  
  Bi-Sexual Yes No Yes No  
  Try-Sexual Yes No Yes No  
             
  Occupation:          
  Height:          
  Weight:          
  Hair Color:          
  Eye Color:          
  Facial Hair:          
  Any Piercings?
If yes, where:
         
  Any tattoos?
If yes, where?
         
  Any brandings?
If yes, where?
         
  Characteristics (things you'd like known about you, physically):          
             
    Dom/me Dom/me sub sub  
  When you climax are you considered one that needs waterproof sheets under you?  Yes No Yes No  
             
  Do you believe you might have? Dom/me Dom/me sub sub  
  Trichomonas/Trichomoniasis or yeast infection?
Explanation:
Yes No Yes No  
  Herpes?
Explanation:
Yes No Yes No  
  Any STD?
Explanation:
Yes No Yes No  
  Chlamydia?
Explanation:
Yes No Yes No  
   Syphilis?
Explanation:
Yes No Yes No  
   Gonorrhea?
Explanation:
Yes No Yes No  
  PID (Pelvic Inflammatory Disease)?
Explanation:
Yes No Yes No  
  TB (Tuberculosis)?
Explanation:
Yes No Yes No  
  Tested positive for HIV/AIDS?
Explanation:
Yes No Yes No  
  Date of last HIV test:          
  Do you believe you might have Hepatitis? Yes No Yes No  
  Have you have Hepatitis vaccination series?
When? What type:
Yes No Yes No  
             
  Check off which of the following sexual acts that are acceptable to you.          
  Dominant to submissive Dom/me Dom/me sub sub  
  Masturbation Yes No Yes No  
  Fellatio Yes No Yes No  
  Cunnilingus Yes No Yes No  
  Rimming Yes No Yes No  
  Anal Fisting Yes No Yes No  
  Vaginal Fisting Yes No Yes No  
  Vaginal intercourse Yes No Yes No  
  Anal intercourse Yes No Yes No  
             
  submissive to Dominant          
  Masturbation Yes No Yes No  
  Fellatio Yes No Yes No  
  Cunnilingus Yes No Yes No  
  Rimming Yes No Yes No  
  Anal Fisting Yes No Yes No  
  Vaginal Fisting Yes No Yes No  
  Vaginal intercourse Yes No Yes No  
  Anal intercourse Yes No Yes No  
    Dominant Dominant submissive submissive  
  Is swallowing of semen acceptable? Yes No Yes No  
  Is oral sex without a barrier okay? Yes No Yes No  
  Will any sex toys such as vibrators, dildoes, butt plugs, ben wa balls, etc. be used? Yes No Yes No  
  Which of the above activities will involve birth control?          
  What birth control are you using?          
  Birth control pills Yes No Yes No  
  Diaphragms Yes No Yes No  
  IUD Yes No Yes No  
  Spermicidal suppositories Yes No Yes No  
  Lubricants containing nonoxynol-9 Yes No Yes No  
  Contraceptive foam/suppositories/gel? Yes No Yes No  
  Which of the above activities will involve:          
  Condoms-Male          
  Condoms-Female          
  Gloves          
  Dental dams or other barriers          
              
8. Intoxicants          
  The dominant can use (only) the following intoxicants during the session:          
  Acceptable quantity:          
  The submissive can use (only) the following intoxicants during the session:          
  Acceptable quantity:          
             
9. Bondage          
  Submissive agrees to allow the following types of bondage:       Any explanations use this column?  
  Hands in front Yes No Wants to try    
  Hands behind Yes No Wants to try    
  Ankles Yes No Wants to try    
  Knees Yes No Wants to try    
  Elbows Yes No Wants to try    
  Wrist to ankles Yes No Wants to try  
  Wrist to ankles (hog-tie) Yes No Wants to try    
  Spreader Bars Yes No Wants to try    
  Tied to a Chair (could be a massage chair also) Yes No Wants to try    
  Tied to a bed Yes No Wants to try    
  Tied to a table (could be a massage table type) Yes No Wants to try    
  Tied to a bench, wooden or metal horse, etc. Yes No Wants to try    
  Use of blindfold Yes No Wants to try    
  Use of gag Yes No Wants to try    
  Use of hood Yes No Wants to try    
  Use of rope Yes No Wants to try    
  Use of handcuffs/metal restraints Yes No Wants to try    
  Use of tape Yes No Wants to try    
  Use of leather cuffs Yes No Wants to try    
  Suspension Yes No Wants to try    
  Acceptable degree of immobility/helplessness: Limited Moderate Extreme    
             
10. Pain/Erotic Pain          
  submissive's general attitude about receiving pain/erotic pain Likes Accepts Neutral Dislikes Will Not Accept
  Quantity of pain/erotic pain submissive wants to receive
Explanation:
None Small Average Large The more the better
  Dominant's general attitude about giving pain/erotic pain Likes Small Average Large Erotic
  Quantity of pain/erotic pain dominant wants to give None Small  Average Large Watch Out!
             
  submissive agrees to accept the following types of pain/erotic pain:          
  Spanking Yes No Wants to try    
  Paddling Yes No Wants to try    
  Whipping/Flogging Yes No Wants to try    
  Single Tail/Bullwhip/Signal Whip Yes No Wants to try    
  Caning Yes no Wants to try    
  Face Slaps Yes No Wants to try    
  Biting Yes No Wants to try    
  Clothespins Yes No Wants to try    
  Clothespins-nipple/breast Yes No Wants to try    
  Clothespins-genital Yes No Wants to try    
  Clamps Yes No Wants to try    
  Clamps-nipple/breast Yes No Wants to try    
  Clamps-genital Yes No Wants to try    
  Clamps any special location?          
  Hot creams Yes No Wants to try < /td>  
  Ice Yes No Wants to try    
  Hot Wax Yes No Wants to try    
  Chemical/Food/Plants  Yes No Wants to try    
  Other types/methods of pain/erotic pain:
Additional remarks:
         
             
11. Marks          
  Is it acceptable to the submissive if the play leaves marks? Yes No      
  Visible while wearing street clothes? Yes No      
  Visible while wearing a bathing suit? Yes No      
  Other:          
  Is it acceptable to the submissive if the play draws small amounts of blood?
Explanation:
Yes No      
   Is it acceptable to the submissive if the play draws large amounts of blood?
Explanation:
Yes No      
  Please be aware marks or drawing of blood can occur even when precautions are taken.          
  How easy or difficult has it been to mark the submissive in the past?          
             
12. Erotic Humiliation          
  The submissive agrees to accept being referred to by the following terms: (circle all that apply)  
Any others?
Cunt Bitch Some sub/slave/bottom name slave Slut
  The submissive agrees to the following forms of erotic humiliation:          
  "Verbal abuse" Yes No Wants to try    
  Exhibition-private Yes No Wants to try    
  Exhibition-public Yes No Wants to try    
  Exhibition-play party Yes No Wants to try    
  Forced to dress in particular clothing to please the Dom/me Yes No Wants to try    
  Enemas Yes No Wants to try    
  Spitting Yes No Wants to try    
  Water Sports Yes No Wants to try     
  Scat games Yes No Wants to try    
  Any prior really good or really bad experiences in those areas?          
             
13. Safe Words          
  Safe Word #1 and it's meaning:
Pink
A bit too hard/overwhelming I need a breather/need to catch my breath.
         
  Safe Word #2 and it's meaning:
Red
This isn't working...check in with me.
         
  Safe Word #3 and it's meaning:
Black
End NOW
         
  If I (the Dom/me) am not responding, have I heard you?
Use my non scene name this will get my attention.
         
  Some dom/me's allow their sub to let them know when 
they hit an area the sub prefers them not too--use the word
"Wrap"
         
  Non verbal safe words and it's meaning:          
  Two-squeezes.  The sub squeezes the Dom/me's hand, knee, arm whatever is negotiated--2 times and the Dom/me will check in with the sub.          
  Ball in the hand, if sub drops the ball the Dom/me checks
in with the sub.
         
             
14. Opportunities/Special Skills          
  Anything in particular either party would like to try and explore?         
           
15. Dominant          
  Check which statement best suits you:          
  I live D/s lifestyle every day in most activities          
  I live D/s lifestyle 24/7          
  I live D/s lifestyle frequently when in relationship          
  I live D/s lifestyle occasionally in relationship          
  I live D/s lifestyle in "scenes" or "play" only          
  I use D/s only in "scenes" or "play"          
  I do not live D/s lifestyle but would use "play" with correct submissive.          
  Which best suits you:          
  On-Line relationship only (may include web cam) Yes No      
  On-Line/Phone Relationship only Yes No       
  Real Time Relationship only Yes  No      
  On-line/Phone/Real Time Relationship Combination Yes No      
  Do you currently have a sub/bottom/slave? Yes No      
  Are you currently seeking a sub/bottom/slave? Yes No      
  Can or would you travel to meet/be with a sub/bottom/slave? Yes No      
  Would you have a sub/bottom/slave travel to meet/be with you? Yes No      
  Have you had previous relationships:          
  Real Life Yes No      
  Only On Line (may include web cam) Yes No      
  Only On Line and by phone Yes No      
  If you answered yes to any of the above, how much experience?          
  Are you experienced with: How much experience?        
  On-line D/s (may include web cam)          
  Phone D/s          
  Real Time D/s          
  Previous Relationships:          
  Have you had a collared sub/bottom/slave? Yes No      
  Why did that relationship terminate?          
  What's your current relationship with that sub/bottom/slave?          
             
  What aspects of your sub/bottom/slaves life would you want to control? (check all applicable)          
  Choose their clothing          
  Choose their food          
  Choose their daily activities          
  Special occasion activities (non-sexual)          
  Sexual activities          
  Choose Social contacts          
  Set Sleeping hours          
  Bathing/toilet rituals          
  Business/professional life          
  Other:           
             
  D/s Social:          
  Would you like a sub/bottom/slave to perform the following and if so, how often (Rating scale: "O" (occasionally) "F" (frequently) "A" (at all times when applicable)          
  Kneeling-clothed O F A    
  Kneeling-naked O F A    
  Wearing bondage outside "scenes" (crotch ropes, etc) O F A    
  Wearing toys outside "scenes" (nipple clamps, butt plugs, etc) O F A    
  Wearing toys/bondage in public (over clothing) O F A    
  Wearing toys/bondage in public (under clothing) O F A    
  Wearing toys/bondage in public (while naked--this could be at a play party) O F A    
  "Correct posture" outside "scenes" (to be defined) O F A    
  Sexual situations in public O F A    
  Wearing D/s collar in public O F A    
  Wearing D/s collar in private O F A    
  Performing "instructions" (delivered on-line/may include web cam or phone) O F A    
  Writing journal entries O F A    
  Would you require a standard form of dress for the sub/bottom/slave in private? (If so what?) O F A    
  Would you require a standard form of dress for the sub/bottom/slave in public? (If so what?) O F A    
  What form of address would you expect from the sub/bottom/slave for yourself and others? (check applicable) Myself Other Dom/me's Other sub/bottom/slave    
  Sir          
  Ma'am          
  Master          
  Mistress          
  First name          
  Mr./Mrs./Ms.          
  Other Males-Dom          
  Other Males-sub/bottom/slave          
  Other females-Domme          
  Other females-sub/bottom/slave           
             
  Would you desire to "share" your sub with others?
If yes, state the circumstances and likely other partners (if known now).
Yes No Depends on situation    
  Would you wish your sub/bottom/slave to have any of the following:          
  Tattoo of ownership Yes No Depends on situation Probably at some point  
  Branding of ownership Yes No Depends on situation Probably at some point  
   Collar (or bracelet/ankle chain) worn 24/7 Yes No Depends on situation Probably at some point  
  Screen name changed to reflect ownership Yes No Depends on situation Probably at some point  
             
  List any "scene" or "play" which you WOULD NOT DO under any circumstances.          
             
  PUNISHMENTS          
  What forms of punishments would you use on a disobedient sub/bottom/slave: (this is NOT play punishment)          
  Writing assignments Yes No Depends on situation  
  Meditation Yes No Depends on situation    
  Corporal Punishment (caning, whipping, etc) Yes No Depends on situation    
  Time out, in the corner, or kneeling looking at the floor Yes No Depends on situation   
  Spanking, naked kneeling or standing nose to the wall Yes No Depends on situation    
  Bondage (any form) Yes No Depends on situation    
  Removal of privileges Yes No Depends on situation    
  Loss of contact with you Yes No Depends on situation    
  Specific Dress Yes No Depends on situation    
  Withholding orgasms/pleasure Yes No Depends on situation    
  Other:          
  Note: All of the above should be within negotiated limits          
             
  What forms of rewards would you give a pleasing sub/bottom/slave:          
  Small "presents" (candy, flowers, etc) Yes No Depends on situation    
  Additional "play" (something special they have been wanting) Yes No Depends on situation    
  Additional "play" time with you Yes No Depends on situation    
  Personal mementos (letters to them, etc) Yes No Depends on situation    
  Going somewhere with them Yes No Depends on situation    
  Time away (mini vacation) with them Yes No Depends on situation    
  Free access/unrestricted access to your body Yes No Depends on situation    
             
  More about you:          
  Non-D/s interests/hobbies:          
Favorite music:          
  Favorite reading:          
  Favorite non-D/s leisure time activities:          
  Any other information you would like to supply regarding yourself:          
             
16. Submissive          
  Check which statement best suits you:          
  I live D/s lifestyle every day in most activities          
  I live D/s lifestyle 24/7          
  I live D/s lifestyle frequently when in relationship          
  I live D/s lifestyle occasionally in relationship          
  I live D/s lifestyle in "scenes" or "play" only          
  I use D/s only in "scenes" or "play"          
  I do not live D/s lifestyle but would use for "play" with correct Dominant.          
  Which best suits you:          
  On-Line relationship only (may include web cam) Yes No      
  On-Line/Phone Relationship only Yes No      
  Real Time Relationship only Yes  No      
  On-line/Phone/Real Time Relationship Combination Yes No      
  Do you currently have a Dom/me? Yes No      
  Are you currently seeking a Dom/me? Yes No      
  Can or would you travel to meet/be with a Dom/me? Yes No      
  Would you like a Dom/me travel to meet/be with you? Yes No      
  Are you experienced with:     How much experience?    
  On-line D/s (may include web cam) Yes No      
  Phone D/s Yes No      
  Real Time D/s Yes No      
  Previous Relationships:          
  Have you had a collar from a Dom/me? Yes No      
  Why did that relationship terminate?          
  What's your current relationship with that Dominant?          
  Have you had previous relationships:          
  Real Life Yes No      
  Only On Line (may include web cam) Yes No      
  Only On Line and by phone Yes No      
  What aspects of your sub/bottom/slaves life would you want controlled by your Dom/me? (check all applicable)          
  Choice of clothing          
  Choice of food          
  Choose your daily activities          
  Special occasion activities (non-sexual)          
  Sexual activities          
  Choose your social contacts          
  Set Sleeping hours          
  Bathing/toilet rituals          
  Business/professional life          
             
  What kind of "play pain" do you enjoy?          
  Sting Yes No Don't know    
  Thud Yes No Don't know    
  Combination Thud and Sting Yes  No Don't know    
  What items do you consider Stingy?          
  What items do you consider Thuddy?          
  What items do you consider both Stingy and Thuddy?          
  List any "scene" or "play" activities which you WOULD NOT DO under any circumstances:          
  Would you desire to be "shared" with others? Yes No Depends on the situation    
  Shared with:          
  Female Dominants Yes No Willing to for Dom/me    
  Female subs/bottoms/slaves Yes No Willing to for Dom/me    
  Male Dominants Yes No Willing to for Dom/me    
  Male sub/bottom/slaves Yes No Willing to for Dom/me    
  Would you have any of the following done for your Dominant?          
  Being pierced? Yes No Depends on situation    
  Tattoo of ownership? Yes No Depends on situation    
  Branding of ownership? Yes No Depends on situation    
  Collar (bracelet or ankle chain) worn 24/7 Yes No      
  Screen name change to reflect ownership Yes No Depends on situation    
            
  PUNISHMENT          
  What would be punishment to you?: (this is NOT play punishment)          
  Writing assignments Yes No Depends on situation    
  Meditation Yes No Depends on situation    
  Corporal Punishment (caning, whipping, etc) Yes No Depends on situation    
  Time out, in the corner, or kneeling looking at the floor Yes No Depends on situation    
  Spanking, naked kneeling or standing nose to the wall Yes No Depends on situation    
  Bondage (any form) Yes No Depends on situation    
  Removal of privileges Yes No Depends on situation    
  Loss of contact with Dom/me Yes No Depends on situation    
  Specific Dress Yes No Depends on situation    
  Withholding orgasms/pleasure Yes No Depends on situation    
  Other:          
  Note: All of the above should be within negotiated limits          
             
  What would you consider a reward for you?          
  Small "presents" (candy, flowers, etc) Yes No Depends on situation    
  Additional "play" (something special you have been wanting your Dom/me to do) Yes No Depends on situation    
  Additional "play" time with Dom/me Yes No Depends on situation    
  Personal mementos (letters to you, etc) Yes No Depends on situation    
  Having the Dom/me take you somewhere Yes No Depends on situation    
  Time away (mini vacation) with Dom/me Yes No Depends on situation    
  Free access/unrestricted access to your Dom/mes body Yes No Depends on situation    
  Postcard from the Dom/me when they are away Yes No Depends on situation    
  A romantic dinner out with the Dom/me Yes No Depends on situation    
  Endorphin Flogging Yes No Depends on situation    
  Oral pleasure from Dom/me to you Yes No Depends on situation    
  Other please state:          
             
  More about you:          
  Non-D/s interests/hobbies:          
  Favorite music:          
  Favorite reading:          
  Favorite non-D/s leisure time activities:          
  Any other information you would like to supply regarding yourself:          
             
17. Follow Up          
  After the session we need a coming down period.
The next day we should discuss how things went.
A week later touch in again/follow up.
         
  In case of crisis:          
             
18. Anything else?          
  Dominant Post-session notes:          
  Best Part:          
  Scale 1-10 (10 being tops)          
  Worst Part:          
  Scale 1-10 (10 being tops)          
  Most memorable part:          
  Scale 1-10 (10 being to tops)          
  Other comments:          
             
  sub/bottom/slave Post-session notes:          
  Best Part:          
  Scale 1-10 (10 being tops)          
  Worst Part:          
  Scale 1-10 (10 being tops)          
  Most memorable part:          
  Scale 1-10 (10 being to tops)          
  Other comments:          
             
19. Please answer these questions completely honestly.
Please use a separate sheet(s) of paper.
         
             
A. What is it about yourself that attracts you to the BDSM play scene?          
             
B. What is it about yourself that attracts you to the BDSM lifestyle?          
             
C. What does being a sub/bottom/slave mean to you?          
             
D. What fantasies have you had that relate to BDSM lifestyle?          
             
E. Describe a scene you would find to be highly erotic, satisfying and descriptive of the role you wish to assume in BDSM.          
             
F. Describe a scene you would find to be non-erotic, non-satisfying and descriptive of the role you wish to assume in BDSM.          
             
G. Describe a scene you would find completely out of bounds or off limits as far as your current disposition and understanding are concerned.          
             
H. What is it about me that makes you think I would be the right Dom/me for you?          
             
I. What sexual fantasies have you had that relate to BDSM?          
             
J. What non-sexual fantasies have you had that relate to BDSM?          
             
K. List the erotic and sexual toys and devices you currently own:          
             

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