Demographic Data


Name ___________________________________
Age ___________ Gender  ___F  ____M

Marital Status: ___ Married ___ Divorced ___ Single ___ Widower/Widow ___ In an Long Term Relationship

 

Military Service: ___ Active ___Retired ___ Reserves ___ None


Contact Information
E-mail Address ________________________________________________
In case of emergency contact*:

Name _____________________________ Relationship________________
Phone ______________________

Transportation / Travel
Do you have reliable transportation? ___Y ___ N


Health Related Issues
Do you smoke? Y N
Do you drink alcohol? Y N (If yes, describe amount consumed each day & week) _____________________________________________________________________________________

 

Do you take illegal drugs? Y N (If yes, what are your drugs of choice?) _____________________________________________________________________________________


Medical Issues


Condition When Diagnosed/Occurred


___ Alzheimer’s __________________
___ Arthritis __________________
___ Asperger's __________________
___ Blindness __________________
___ Cancer __________________
___ Chlamydia __________________
___ COPD __________________
___ Cystic Fibrosis __________________
___ Diabetes (Type 1) __________________
___ Diabetes (Type 2) __________________
___ Edema __________________
___ Gonorrhea __________________
___ HIV/AIDS __________________
___ Hyperglycemia __________________
___ Hypoglycemia __________________
___ Heart Disease __________________
___ Multiple Sclerosis __________________
___ Muscular Dystrophy __________________
___ Myasthenia Gravis __________________
___ Physical Disability __________________
___ Spina Bifida __________________
___ STD (other) __________________
___ Stroke __________________
___ Other (affecting your ability to serve or session) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Psychological Conditions
___ Bi-Polar
___ Borderline Personality
___ Dissociative Identity Disorder (DID
___ Gender Dysphoria
___ Schizophrenia
___ Other ________________________________________________________________________________

Relationships


How long has it been since you’ve been in a relationship? __________________________________________
If married or in a relationship currently, is your partner aware that you have approached me?
___ Y ___ N
Does your spouse/SO have an interest in D/s or BDSM lifestyles? ___Y ___ N
Do you plan to involve them in your service/sessions/relationships in the lifestyle? ___ Y ___ N
How many D/s and BDSM relationships have you been in? _________________________________________
Describe what you liked and disliked about those prior relationships ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(asked to determine emotional availability and level of experience)
Submission
Describe your submissive philosophy/ethics ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
In lifestyle scene terms, you would be considered primarily:
___ Switch  ___ Bottom ___ Masochist ___ Slave ___ Pet ___ Service Submissive ___ Slut ___ Novice
___ Other ________________________________________________________________________________

Lifestyle Preferences (rank in order)


___ Power Exchange (Domination and submission)
___ BDSM Activities
___ Social Activities
___ Other ________________________________________________________________________________


Preferred Presentation _____________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Hard Limits_______________________________________________________________________________
________________________________________________________________________________________

_______________________________________________________________________________________________________________

Preferred D/s Naming (mark all that are permissible to use)
___ Pet ___ Slave ___ Slut ___ Bitch ___ Cunt ___ Faggot ___It
___ Worm ___ Loser ___ ATM ___ Piggy ___ Other Animal(s) ______________________________________
Other ___________________________________________________________________________________

 

D/s & BDSM Interests

 

My interests are ___________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


My top 3 favorite scenes / fantasies are ________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are you seeking and why (essay of 500 – 1000 words)?

________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Anything else you might wish to say? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any questions for Me? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student of Mistresses

Simone Justice & Damiana Chi

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