Client Survey
Please complete the survey and do so as detailed as possible. The information you provide will help your Mistress understand your needs, boundaries, and will enhance your play time. For couples, please complete the survey individually.
Email address *
Name *
Slave Name
Phone number
Age
Can you recieve Calls/Voicemals?
Clear selection
Please check fetishes that interest you
Which session dynamic do you respond to best?
What is your pain tolerance level?
Be careful what you wish for... :-)
No pain
Torture me!
Clear selection
Does scent play interest you?
Clear selection
What part of your session are you most looking forward to?
Is there anything about being with a Domme that you feel nervous about?
What are your hard limits?
Clear selection
1st choice session date *
MM
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DD
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YYYY
Time *
Time
:
2nd choice session date *
MM
/
DD
/
YYYY
Time *
Time
:
INFORMED CONSENT STATEMENT; I am requesting and at my own risk participating in a BDSM session. I understand activities within the Session will be conducted by mutual consent. I accept sole responsibility to; (a) decide what activities I wish to participate in during the Session and decide what my boundaries are. (b) communicate these decisions clearly before the start of the Session. (c) agree to an appropriate safe word or other signal to request an activity stop. (d) signal immediately, any unexpected fatigue, shortness of breath, chest discomfort, nausea, pain or discomfort. I understand I can discontinue participation at any time during the Session, without prejudice against me, beyond fees or tribute for the Session. LIMITS OF LIABILITY; I understand that any activity undertaken during the Session are voluntary and are at my own risk. I agree to indemnify and hold harmless all participants in the Session from all claims of liability, injury, death, property loss or damage, attorney’s fees and costs and I agree to reimburse them for any such claims; of same, they may have. AGREEMENT; by checking the box and submitting this session application, I acknowledge I have read, understood and agree to the contents of this form and I confirm that all information given by me, is correct to the best of my knowledge. I understand there is no sex involved in Miss Jane's sessions, I am a consenting adult over the age of 21 and I am not a law enforcement officer or federal law enforcement agent. *
Required
A copy of your responses will be emailed to the address you provided.
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