Application

Sessions are more successful when your Dominant knows a bit about you. Carefully read each question and mark the answer(s) that best applies. you are not required to answer all questions.

A very detailed introductory email may be sent to My email in lieu of filling out the application MissMedusaStone@gmail.com. The application is here to help those along who might be an obmutescent penman.

Name
E-Mail Address
Discreet Phone Number And Best Time To Call
Age
Height/Weight
Location

Section I: Personal Information

1. Which best describes your experience level?

First timer. I have never seen a Professional Dominant before

Novice. I've had a session or two in my time

Experienced. I've had many sessions

If you have had ANY experience, with whom, how long ago, and can you use them as a reference?

2. How did you find out about Me?

3. What is your marital status?

4. What is your gender?

5. Are you now or have you ever been associated with law enforcement, a municipality, a government agency or the media?

Yes Please explain.

No

6. Without revealing where you work, what do you do for a living?

7. Do you consider yourself submissive (i.e. you enjoy submitting to a Dominant)?

Yes

Maybe

No

8. Do you consider yourself a masochist (i.e. do you derive pleasure from receiving pain)?

Yes

Mild

Moderate

Severe

Unsure

No

9. Do you consider yourself a fetishist (i.e. do you derive sexual arousal from an object, substance, body part, or activity)?

Yes

Unsure

No

10. With regard to BDSM (Bondage, Discipline, and Sadomasochism), which form interests you?

Physical aspects (e.g. whipping, bondage, torture)

Psychosexual. mental aspects (e.g. crossdressing, humiliation, fetishism, role play)

Both. I believe they are equally important

11. List the top three things you hope to explore during this session

A

B

C

12. Have you had any bad experiences with a Professional Dominatrix in the past?

Yes, please explain

No

Section II: Health Survey

In order to ensure your safety and well being, it is important that you disclose any issues that may affect you during a session. Carefully read each question and denote the answer(s) applicable to you.

13. Are you currently under a doctor's care for a pre-existing condition?

Yes, please explain

No

14. Are you currently on medication?

Yes, please explain

No

15. Do you have any non-seasonal allergies (particularly to Nonoxynol-9, Latex, Iodine, or Shellfish)?

Yes, please explain

No

16. Do you currently have or have you recently been exposed to any sexually transmitted diseases?

Yes, please explain

No

17. Do you have any of the following medical conditions? Denote all that apply.

Diabetes

Anemia

Epilepsy

Asthma

Hypoglycemia (low blood sugar)

Heart Disease

Lung Disease

Hypertension (high blood pressure)

Hypotension (low blood pressure)

Hemophilia

No

18. Do you ever experience any of the following? Denote all that apply.

Dizziness

Fainting

Blackouts

Seizures

Difficulty breathing

No

19. Have you had surgery within the last year?

Yes, please explain

No

20. Do you have any prosthetic devices, pins, screws, plates, etc.?

Yes, please explain

No

21. Are you wearing any of the following? Denote all that apply.

Hearing aid

Dentures/Partials

Contact lenses

Glasses

Insulin pump

Pacemaker

No

22. Are you claustrophobic (i.e. do you have an abnormal fear of tight spaces)?

Yes

No

23. Do you have skeletal, muscular, or joint problems?

Yes, please explain

No

24. Please list any medical issues, not mentioned above, that might impact your session.

Section III: Attitudes and Interests

Understanding your attitudes toward certain aspects of BDSM will help your Dominant determine your limits and areas of interest. This will help your Dominant create a fulfilling scene and lead a successful session. Read each question carefully. Then, choose the response(s) that best apply to you. Please denote ALL that apply!

25. About which of the following do you most often fantasize?

A strict, demanding Dominant

A sensual, teasing Dominant

26. About which of the following do you most often fantasize?

A session ending in release

A session ending in denial

27. What is your mark limit?

Temporary redness. leave here unscathed

Souvenirs. marks that last a few days

My butt should look like a road map and these marks should last a week

28. Bondage. Denote all that interest you.

Muzzle

Gag

Cage

Rope

Wrist and ankle cuffs

Spreader bars

Chains

Dungeon furniture- Spanking bench, table, suspended sling, bondage horse, torture chair, St. Andrew's cross, bondage table

Latex vacuum bed

Plastic wrap mummification

Strait jacket

Suspension

29. Corporal Punishment. Denote all that interest you. Keep in mind your Dominant will only use these implements in a manner consistent with your mark limit.

Spanking. Dominants hand, OTK

Paddling. wood, Lexan, leather

Domestic. hair brush, wooden spoon, spatula, carpet beater

Flogging. bungee, leather, suede, rope, fur

Cropping. riding crop, jump bat

Whipping. dressage whip, stinger, slapper, tawse, single tail, strap

Beating. pain stick, rubber hose, truncheon

Caning. rattan, Lexan, rod, birch faggot

30. Humiliation. Denote all that interest you

Verbal abuse

Spitting

Hair pulling

Face slapping

Collar and leash

Boot/shoe worship

Foot worship

Watersports- golden shower, golden cocktail

Forced feminization (crossdressing)- Clothing, makeup, wig, high heels, boots

Dildo training- anal, oral or both

31. S&M. Denote all that interest you.

CBT (cock and ball torture) Slapping, pinching, pulling, light whipping, cages, rings, clothespins, rope bondage, parachute, weights, chastity, ball crusher

Nipple Torture- Slapping, pinching, pulling, light whipping, clothespins, clamps, weights

Electro-play- Tennis racket zapper, Violet wand, TENS unit

Fire and ice- Low temperature candle wax, ice, higher temperature candle wax

Edge play- Breath control, branding, cutting

32. Sensory deprivation. Denote all that interest you.

Blindfold

Hood

Earplugs

33. Role play. Denote all that interest you.

Amazon/captive

Boss/employee

Cop/criminal

Interrogator/prisoner

Kidnapper/victim

Nun/parishioner

Nurse/patient

Owner/slave

Queen/subject

Teacher/student

34. Animal training. Denote all that interest you.

Kennel training. you're a puppy, your Dominant is your trainer

Pony play. you're a horse, your Dominant is your rider/driver/trainer

Other, please explain

35. Depersonalization. Denote all that interest you.

Human ashtray

Human footstool

Human chair

Human floor

36. Fetishism. Denote all that interest you.

Leather

Latex(rubber)

Spandex

PVC

Feet- Massages, pedicures, stocking feet, bare feet, dirty feet

Retifism- Shoe worship, boot worship

Trampling

Smoking

Smothering

Fingernails

Hair

Tickling

Stockings

Pantyhose

High heels

Boots

Other - Explain

37. Is there anything else you would like Me to know?

Even though this gives Me an idea of your background, interests, and limitations, I and I alone dictate what takes place in a session. The information given to Me are tools in understanding who you are and where you are coming from. This will make a better experience for both parties involved.

If you do not see your kink or fetish listed here, simply email Me to discuss the details. This world is ever changing and new interests develop every day, so just because it is not listed, doesn't mean it cannot be done.