FETISH FORM
ALL FORMS ARE KEPT STRICTLY CONFIDENTIAL!

SUBMIT A COMPLETED FETISH EXPERIENCE QUESTIONNAIRE PRIOR TO INQUIRING ABOUT KINK THERAPY TREATMENT OPTIONS. ANSWER EACH QUESTION HONESTLY!

Email address *
Name *
First and Last Name
Your answer
Mobile Number *
A VALID phone number where you can be reached via Voice or Text. DO NOT USE A GOOGLE VOICE NUMBER!!!
Your answer
Where are you located? *
Type in your location here
Your answer
How did you find Me or My website?
Did you use a search engine? If so, which one? What words did you type into the search bar? Did you find Me through another website? List the website or directory URL here. Or was it social media? Explain how you found Me and My website below.
Your answer
Date of desired Appointment for Kink Therapy *
Select a date you want to schedule for a session
MM
/
DD
Time
:
Type of Appointment Requested *
We offer 4 different categories
Appointment Type Requested: *
Select the type of appointment requested.
Required
Can you afford the $500 minimum? *
Check ALL your bondage interests: *
Check everything you would like to try or want to try
Required
If you have ANY other Bondage interests that are NOT listed above, add them here or type "NONE" *
Your answer
Select ALL your Fetish Interests: *
Check your likes, needs and/or wants.
Required
If your Fetish is NOT listed above then add it here or type "NONE" *
Your answer
Please select ALL your Psycho-dramatic role playing fantasies: *
Check ALL that apply.
Required
If your Psycho-dramatic role playing fantasy is not listed above then add your fantasy here or type "NONE": *
Your answer
Select ANY slave training programs that interest you: *
Check ALL programs that interest you.
Required
Fantasy Story Telling! *
DESCRIBE ANY OTHER FANTASIES YOU MAY HAVE
Your answer
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