Application Form

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 submitting it to me or bring it in person upon your visit.

(* Denotes a required field)
Name*
Slave Name
Age
Nationality
Home Town/City
Occupation
Email Address*
Phone Number*
Is it ok to leave a discreet voicemail on this number? YES
NO

How did you hear about me? Serious Mistresses
Professional Mistresses
Twitter
Found me on Google
Another Mistress Directory - if so please state which one at the bottom of the page

Health Status Heart problems
Spinal Problems
Joint Problems
Injuries
High/low blood pressure
Diabetes
HIV

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
Bit of everything
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 (Soles of the Feet)
Blindfolds
Body Piercing (additional charge)
Body Worship (not intimate)
Bondage
Extended Bondage
Ball Busting
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
Degradation
Depilation (Shaving)
Deep Heat Treatments
Discipline
Domestic Servitude
Electrics
Flogging
Financial Domination/Slavery
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
Smothering Face Sitting
Spanking
Spitting
Suspension Bondage
Talons
Tickling
Trampling
Violet Wand
Watersports
Weights

Are you Male or Female? Male
Female

Required Appointment
(Please state duration and date/time)







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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.