Application - Lady Rochester

During my consultations with all first time clients, I ask the questions listed below to assist me in developing an understanding of my subjects’ needs. I prefer that you answer these questions prior to the session by filling out this questionnaire and emailing it to me or bring it in person upon your visit.

Name:
Slave Name:
Date of Birth:
Nationality:
Home Town/City:
Occupation:
Your Email Address:
Phone Number:
Is it ok to leave a discreet voicemail on this number?	YES NO
How did you hear about me?	OWK DDI Mag Tied and Teased Mags Serious Mistresses Other (Please Specifiy)
Health status:	Heart problems Spinal Problems Joint Problems Injuries High/low blood pressure Diabetes HIV
Do you suffer from any phobias and if so how does this affect you?
Do you have any other health issues the Mistress should know about?
Can you be marked?	YES NO
Which of the following most describes you:	Masochistic Submissive Fetishist Just exploring
What is your sexuality?	Hetrosexual Bi-curious Bisexual Gay
Regarding S&M:	No pain for me! I will take pain to please you, Mistress. I enjoy pain and can take a moderate amount. I crave pain and torture.
Your level of experience of BDSM play is:	Novice Some personal play Experienced
I wear whatever I choose but sometimes I may feel like treating you. Which of the following would you most like to see me in:	Leather PVC Rubber Uniform/fantasy wear Boots Stilettos Stockings Catsuit Corsets Jodhpurs Other (Please specify):
Which of the following activities do you enjoy most as a submissive or wish to explore further:	Anal (Dildos/Strap ons) Anal purification (enemas) Asphxiaphillia (Breath play) Bastinado Blindfolds Body Piercing (additional charge) Body Worship Bondage Extended Bondage Boot worship Branding Caning Caging Chains Candle wax Chastisement Clips and clamps Cling Film Clit torture Cock and ball torture Collar & Lead Crops and whips Cross dressing or gender play Depilation (shaving) Deep heat treatments Discipline Domestic servitude Electrics Flogging Foot Fetish Fisting Forced bisexuality Gags Glove worship High Heel Torture Hair Pulling Humiliation (Physical/Verbal) Ice Play Lady in waiting servitude Masks/Hoods Medical Play Mummification Needle Play Neglect Nipple Torture Oral strap on training Paddling Pet training Role Play Rope Bondage Sensory Deprivation Slapping Smoking fetish/ashtray training Smothering face sitting queening Spanking Suspension Bondage Talons Tickling Trampling Violet Wand Watersports Weights
Are you interested in Domination via Email? (4 lessons per month @ £30.00)	YES NO
Required Appointment: (Please state duraion and date/time)
I am a lifestyle domina and the information you have provided me with will assist me in understanding your deep routed desires. It will help me to make your visit one to remember for I hold the keys to the kingdom of your fulfilment.

All information you have supplied is strictly confidential and will be kept secure.

Please make sure you understand that by using this site you are agreeing to this disclamer.