|
1. People
Who will take part?__________________________________________________________
Note: All participants must be over 21 years old.
Who will watch? ____________________________________________________________
Note: The session will involve only those people specifically named above.
- Will any permanent record be made of the session: photographs, audiotapes or
videotapes? [ ] Yes [ ] No
Explanation: _______________________________________________________________
2. Roles
Who will be dominant? _______________Who will be submissive? ___________________
Type of scene: master/slave mistress/slave/ captive servant/butler/Etc
cross-dressing/gender play/age play/other:_______________________________________
Any chance of switching roles? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Will the submissive promptly obey? [ ] Yes [ ] No
Explanation: _______________________________________________________________
May the dominant ”overpower” or ”force” the submissive? [ ] Yes [ ] No
Explanation: _______________________________________________________________
May the submissive verbally resist? [ ] Yes [ ] No
Explanation: _______________________________________________________________
May the submissive physically resist? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Does resistance equal ”strong yellow”? [ ] Yes [ ] No
Explanation: _______________________________________________________________
May the submissive try to ”turn the tables”? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Does the submissive agree to wear a collar? [ ] Yes [ ] No
Explanation: _______________________________________________________________
The submissive agrees to address the dominant by the following title(s):
__________________________________________________________________________
- 3. Place
Location: __________________________________________________________________
Who will ensure privacy? _____________________________________________________
4. Time
Begin at: _______________________________Length:____________________________
Beginning signal:___________________________________________________________
- Ending signal:______________________________________________________________
Who will keep track of time? __________________________________________________
5.Oops
Does everybody involved understand that there is some risk of accident,
miscommunication, misperception and/or injury? [ ] Yes [ ] No
Does everybody involved agree to discuss any mishaps in a constructive and
non-blaming manner? [ ] Yes [ ] No
6. Limits - Submissives limits
Submissive’s physical/emotional activity limits:___________________________________
Any problems with the submissive’s…
heart: [ ] Yes [ ] No lungs: [ ] Yes [ ] No neck/back/bones/joints: [ ] Yes [ ] No
kidneys: [ ] Yes [ ] No liver: [ ] Yes [ ] No nervous system/mental: [ ] Yes [ ] No
Explanation: _______________________________________________________________
Is the submissive wearing contact lenses? [ ] Yes [ ] No
Does the submissive have a history of…
seizures: [ ] Yes [ ] No dizzy spells: [ ] Yes [ ] No diabetes: [ ] Yes [ ] No
high or low blood pressure: [ ] Yes [ ] No fainting: [ ] Yes [ ] No
hyperventilation attacks: [ ] Yes [ ] No asthma [ ] Yes [ ] No
Describe any phobias: _______________________________________________________
- Submissive’s other medical conditions: _________________________________________
Any surgical implants (breats, face etc)? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Is the submissive taking aspirin? [ ] Yes [ ] No
Is the submissive taking ibuprofen, Aleve, or other non-steroidal, anti-inflammatory
drugs? [ ] Yes [ ] No Is the submissive taking antihistamines? [ ] Yes [ ] No
Other medications submissive is taking? _______________________________________
- Allergic to: ________________________________________________________________
bandage tapes: [ ] Yes [ ] No monoxynol-9: [ ] Yes [ ] No
Other allergies: ____________________________________________________________
In case of emergency notify: __________________________________________________
- Dominant’s limits
Dominant’s physical/emotional limits: __________________________________________
Any problems with the dominant’s…
heart: [ ] Yes [ ] No lungs: [ ] Yes [ ] No neck/back/bones/joints: [ ] Yes [ ] No
kidneys: [ ] Yes [ ] No liver: [ ] Yes [ ] No nervous system/mental: [ ] Yes [ ] No
Explanation: _______________________________________________________________
Dominant’s other medical conditions: ___________________________________________
Medications dominant is taking:________________________________________________
In case of emergency notify: __________________________________________________
Is the dominant currently certified in First Aid/CPR? [ ] Yes [ ] No
Safety gear on hand: ________________________________________________________
paramedic scissors: [ ] Yes [ ] No flashlight: [ ] Yes [ ] No first aid kit: [ ] Yes [ ] No
blackout light: [ ] Yes [ ] No fire extinguisher: [ ] Yes [ ] No
Will the play be in an isolated area such as a farmhouse? [ ] Yes [ ] No
If yes, what will ensure the submissive’s safety if the dominant becomes unconscious?
no bondage to chair, bed,etc.: [ ] Yes [ ] No third person present? [ ] Yes [ ] No
telephone/radio/panic button within submissive’s reach: [ ] Yes [ ] No
Other: ____________________________________________________________________
7. Sex
Does any participant believe they might have sexually transmitted disease?
[ ] Yes [ ] No Explanation: ____________________________________________________
Does any participant believe they might have herpes? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Have participants been tested for HIV? [ ] Yes [ ] No
Has any participant tested positive? [ ] Yes [ ] No
Explanation: _______________________________________________________________
Circle which of the following sexual acts are acceptable:
Masturbation dominant to submissive submissive to dominant
self-masturbation by submissive self-masturbation by dominant
Fellatiodominant to submissivesubmissive to dominant
Cunnilungus dominant to submissivesubmissive to dominant
Analingus dominant to submissivesubmissive to dominant
Anal fisting dominant to submissivesubmissive to dominant
Vaginal fisting dominant to submissivesubmissive to dominant
Vaginal intercoursedominant to submissivesubmissive to dominant
Anal intercoursedominant to submissivesubmissive to dominant
Is swallowing semen acceptable? [ ] Yes [ ] No
Is any participant menstruating [ ] Yes [ ] No
Will sex toys such as vibrators, dildoes, butt plugs, etc.be used? [ ] Yes [ ] No
Describe: ____________________________________________________________________
Which of the above activities will involve birth control pills, diaphragms, spermicidal
suppositories, lubricants containing nonoxynol-9, or contraceptive foam/suppositories/gel?
__________________________________________________________________________
Which of the above activities will involve:condoms,gloves,dental dams,and/or other barriers?
__________________________________________________________________________
8. Intoxicants
Note: Alcohol or other drugs are not allowed in this play.
Acceptable quantity of cigarettes for the dominant: _________________________________
Acceptable quantity of cigarettes for the submissive: _______________________________
9. Bondage
The submissive agrees to allow (only) the following types of bondage:
hands in front: [ ] Yes [ ] No hands behind back: [ ] Yes [ ] No ankles: [ ] Yes [ ] No
knees: [ ] Yes [ ] No elbows: [ ] Yes [ ] No wrists to ankles (hog-tie): [ ] Yes [ ] No
spreader bars [ ] Yes [ ] No tied to chair: [ ] Yes [ ] No tied to bed: [ ] Yes [ ]
use of blindfold: [ ] Yes [ ] No use of gag: [ ] Yes [ ] No use of hood: [ ] Yes [ ] No
use of rope: [ ] Yes [ ] No use of tape: [ ] Yes [ ] No
use of handcuffs/metal restraints:[ ] Yes [ ] No
use of leather cuffs: [ ] Yes [ ] No suspension: [ ] Yes [ ] No
mummification with plastic wrap,body bag,or similar techniques [ ] Yes [ ] No
Any past bad experiences by either person with bondage, gags, blind folds, and/or
hoods? [ ] Yes [ ] No
Explanation: ________________________________________________________________
10. Pain
Submissive’s general attitude about receiving pain:
[ ]likes [ ]will [ ]give [ ]neutral [ ]dislikes [ ]will not accept
Quantity of pain submissive wants to receive:
[ ]none [ ]small [ ]average [ ]large
Explanation: ________________________________________________________________
Dominants general attitude towards giving pain:
[ ]likes [ ]will [ ]give [ ]neutral [ ]dislikes [ ]will not give
Quantity of pain dominant wants to give: [ ]none [ ]small [ ]average [ ]large
Explanation: ________________________________________________________________
Will the ”low” technique be used? [ ] Yes [ ] No
Explanation: ________________________________________________________________
Will the ”nod” technique be used? [ ] Yes [ ] No
Explanation: ________________________________________________________________
Will the ”one to ten” technique be used? [ ] Yes [ ] No
Explanation: ________________________________________________________________
The following types of pain are acceptable:
spanking: [ ] Yes [ ] No paddling: [ ] Yes [ ] No whipping: [ ] Yes [ ] No
caning: [ ] Yes [ ] No face slaps: [ ] Yes [ ] No biting: [ ] Yes [ ] No
nipple clamps: [ ] Yes [ ] No genital clamps: [ ] Yes [ ] No
clamps elsewhere: [ ] Yes [ ] No locations: _______________________________________
hot creams: [ ] Yes [ ] No ice: [ ] Yes [ ] No hot wax: [ ] Yes [ ] No tickling: [ ] Yes [ ] No
Other types/methods of 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 bathing suit? [ ] Yes [ ] No
Other: _____________________________________________________________________
Is it acceptable to the submissive if the play draws small amounts of blood?
[ ] Yes [ ] No
Explanation: ________________________________________________________________
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:
___________________________________________________________________________
The submissive agrees to the following forms of erotic humiliation:
”verbal abuse”: [ ] Yes [ ] No enemas: [ ] Yes [ ] No forced exhibitionism: [ ] Yes[ ] No
spitting: [ ] Yes [ ] No water sports: [ ] Yes [ ] No scat games: [ ] Yes [ ] No
Other: _____________________________________________________________________
Any prior really good or really bad experiences in this areas?
___________________________________________________________________________
13. Safewords
Safeword no:1 and it´s meaning: _______________________________________________
Safeword no:2 and it´s meaning: _______________________________________________
Safeword no:3 and it´s meaning: _______________________________________________
Non-verbal safewords and their meaning: ________________________________________
_Will ”two squeezes” be used? [ ] Yes [ ] No
Will the ”extended hand” technique be used? [ ] Yes [ ] No
14. Opportunities/Special Skills
Anything in particular either party would like to try or explore?
__________________________________________________________________________
15. Follow-up
(Please include a note about who will initiate contacts.)
After the session: ___________________________________________________________
The next day: _______________________________________________________________
A week later: _______________________________________________________________
In case of crisis: ____________________________________________________________
16. Anything else?
What will become of this form after the session? __________________________________
Post-session notes
Dominant
Overall feeling: _________________________________________________one to ten scale
Best part: ____________________________________________________ _one to ten scale
Worst part: ___________________________________________________ _one to ten scale
Other comments: ______________________________________________ _one to ten scale
Submissive
Overall feeling: _________________________________________________one to ten scale
Best part: _____________________________________________________ one to ten scale
Worst part: ____________________________________________________one to ten scale
Other comments: _______________________________________________one to ten scale
©Copyright 1996 by Jay Wiseman, P.O Box 1261, Berkeley, CA 94701. |
