


To Book an Appointment Call 07983 540576 International +44 7983 540576	To Talk to Me Live Call 0982 666 2200 (UK Only)	To Chat with Me on Yahoo! Click	To Text Chat with Me Text 'MRD' to 89077 (UK Only)

Consultation Form

Mistress holds a consultation with all first time clients, slaves, and submissive sissy's. Mistress asks 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 pressing the submit button at the bottom of this form.

Name
Slave Name
Date of Birth
Nationality
Home Town/City
Occupation
e-mail Address
Telephone Number (optional)
Is it ok to leave a discreet voicemail on this number?		Yes
		No
How did you hear about me?				Search Engine i.e. Google
				Serious Mistresses Magazine
				seriousmistresses.com
				Club Severine
				BDSM.net
	Other (Please Specify)

Health Status				Heart Conditions
				Spinal Problems
				Joint Problems
				Injuries
				High or Low Blood Pressure
				Diabetes
				HIV
Do you suffer from any phobias and if so how does this affect you?
Do you have any health issues that the Mistress should know about?
Do any members of your close family suffer from any of the above?
Can you be marked?		Yes
		No
Which of the following most describes you?				Masochistic
				Submissive
				Fetishist
				Just Exploring
Regarding S&M				No pain for me!
				I will take pain to please you, Mistress
				I enjoy pain and can take a moderate amount
				Just Exploring
Your level of experience of BDSM play is?			Novice
			Some personal play
			Extensive experience
			Other
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
	Other (Please Specify)

Which of the following activities do you enjoy most as a submissive or wish to explore further?			Anal (Dildos/Strap-on)
			Blindfolds
			Bondage
			Caning
			Caging
			Chains
			Candle Wax
			Clips & Clamps
			Cling Film
			Cock & Ball Torture
			Collar & Lead
			Crops & Whips
			Cross Dressing & Gender Play
			Depilation (Shaving)
			Discipline
			Domestic Servitude
			Electrics
			Eunuch Initiation
			Flogging
			Foot Worship
			Forced Feminisation
			Forced Bi-sexuality
			Gags
			Glove Worship
			Hand Worship
			High Heel Torture
			Hair Pulling
			Humiliation (Physical/Verbal)
			Imprisonment (Capture Fantasy)
			Lady in Waiting Servitude
			Leg Worship
			Masks & Hoods
			Mummification
			Nipple Torture
			Oral Strap on Training
			Paddling
			Pony Training
			Role Play
			Slapping
			Spanking
			Shoe Worship
			Sissification
			Tickling
			Trampling
			Waxing
What would you find the most physically appealing about your ideal Mistress?			Her overall looks
			Her bottom
			Her Legs
			Her Breasts
	Other (Please Specify)

If you could have your perfect scenario, what would it be? .
Do you have any other information I should be aware of or anything you would like to ask me? Please indicate when you would like a session with me.

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.