My Form

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Name: Date:  

Website found me on: what is your profile name:  

Email Address:                                Phone Number:  

When is the best time to contact you?  

What City and State do you live in:  

Are you interested in: hourly rate___ monthly rate___  DOB:

Height: Weight:  

Married:  Yes___ No___  

Gender:                Shoe Size:             Shirt size:                      Pant size:  

Describe yourself physically:  

What is the most erotic time you can remember having?  

When you watch porn what kind do you watch?  

Do you feel guilty after you jack off?  

Do you feel guilty after you pleasure the women/men in your life?  

Do you feel you are punishing yourself in anyway for things in the past?  

When you jack off, what do you fantasize about?  

Is anything else missing in your life?  

What religion are you?  

If you are not married, and have been looking for a relationship, what is holding you back?  

Have you seen a Pro Domme before?              How many times?  

How long have you been interested in BDSM, fetishes, ect.?  

Do you have any prior surgeries, medical conditions, phobias, etc.?  

Do you have any metal plates or pins, a pacemaker, insulin pump, or other electronically operated device?  

Do you have a history of heart disease, nerve damage, diabetes, high blood pressure, or hemophilia?  

What are your hard limits (activities you don’t want to do)?  

Is bruising or marking okay? (when being spanked one can bruise)  

Describe your primary interests (you may have experience but maybe not): Please mark E if you experienced and F if you have fantasized about it  ___Fetish ___Submissive ___Role Play ___Cross Dressing  ___Humiliation   ___Bondage   ___Spanking   ___Blindfolds   ___Leather  ___Breast/Nipple clamps ___Candle Wax ___Chastity Devices  ___Cock/Ball Torture ___Collar & Lead/Leash ___Depilation/Shaving   ___Lingerie   ___Foot Fetish   ___Pantyhose/Stockings   ___Shoe Fetish  ___Whips   ___Body Worship    ___Voyeurism   ___Strap On     

___ Adult Baby/Diapers   ___Age Play   __Forced Bi    ___Shopping  

Age play or Cross Dressing do you have your own items? ___Yes ___No  

List Items:  

If we chatted before or on another site explain what we talked about….