Name *

First Name

Last Name

Date of Last Session with Me

If applicable, provide a general date of your last session.

MM

DD

YYYY

What feelings are you searching for this session? *

Proud and appreciated for your efforts

Connection, touch, and sensation

Pushed & broken

Release/Submission

Beautiful/Sexy

Embarassed & teased lovingly

Degraded & humiliated cruelly

Low/worthless

Have you reviewed my scheduling requirements and cancellation policy? *

Yes, I understand and agree to all scheduling protocol and Your cancellation policy

No, I have not sufficiently reviewed Your website.

Were you forced or coerced to submit this application? *

Yes

No

Are you legally competent and able to provide informed consent? *

Yes

No