Consultation Form

Consultations with all  first time clients, slaves, and submissive sissy's. I, your Mistress ask 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.

 
Copyright © Madam Raison D'être 2007-2008 Photographs © John Dietrich 2007-2008