* indicates required field.

Name*:
Email Address* (I prefer all initial contact via email. We will have a chance to speak over the phone once our session time is confirmed):
Age* (if you are under the age of 21 you will not be able to book a session):
Days of the week you are available* (mark all that apply): Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred session start time: 11pm-3pm
3pm-6pm
6pm-9pm
9pm-later
Length of session*:
Preferred location*:
Which of the following roles do you identify with? adult baby
cross dresser
fetishist
masochist
pet
sissy
slave
submissive
other
What are your major fetishes?
What are your favorite activities/interests?*
What are your limits/boundaries?*
Do you have any new activities you are interested in exploring? If so, elaborate.
List any medical conditions I need to be aware of:
Describe your past experience with BDSM:
Provide two verifiable references from previous providers; include their name, e-mail address, and website address. If this is your first time contacting a Mistress, write "new submissive" in the text box*:
Tone of session (mark all that apply): playful
sensual
strict
forceful
Any further questions or comments:
Do you agree you are a consenting adult over the age of 21?* yes
no
Do you understand there is absolutely no sex offered or implied?* yes
no