Mistress Portia's BDSM Application
Application for Prodomme Session
Email address *
Application instructions: I take confidentiality VERY serious (both yours and mine). All information given is strictly confidential, for my eyes only!!!! Please be honest and forthcoming with your answers. The information will help me identify your experience level, interests, and allow me to design a session specifically for you. The more I know, the better your session(s) will be. You must complete the entire application to be considered for a session.
**Be smart, DO NOT use your work email or a personal account others can access if they do not know about your BDSM activities
Personal information:
Name (first & last, be honest, all info is confidential) *
Your answer
City & State where you reside (do not need full address) *
Your answer
Phone number (numbers only, no dashes or spaces, used for verification purposes only, I will not be calling and I do NOT do over the phone applications) *
Your answer
How did you hear about my services? (what website, person, publication) *
Your answer
Are you (check the option below that applies) *
If couple, please provide name of 2nd party, relationship (married, dating, master/slave, dom/sub, or whatever applies)
Your answer
Medical Information: (Check all that apply) *
Please list all medications you currently take. If none, say, "none." *
Your answer
Please briefly explain any of the medical conditions checked above (include known PTSD triggers). If none were checked, simply say, "none." *
Your answer
What is your level of experience with BDSM? *
Have you visited a BDSM professional before (hookers do not count) *
Can you have marks? *
Do you mark easily? *
Check the box beside anything you would like to include, or try, in a session(s)
If you checked CBT above, please check the specific things you have tried, or may want to try.
If you checked any of the CBT options above, which ones have you actually experienced, and which are you hoping to try?
Your answer
Please explain any additional thoughts or fetish ideas you wish me to consider below: *
Your answer
Please describe how you envision a session with me, and what that might include. (answer this in detail, I ask for good reason!!) *
Your answer
A copy of your responses will be emailed to the address you provided.
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