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