I. PEOPLE 

A. Who will take part (i.e., people in direct participation in the session)? 

B. Can anyone be watching (e.g., public dungeon, play party, strictly private)? 

C. Can any recording be made of the session (e.g., photographs, video, audio-tapes)? 

D. How confidential does the session have to be (i.e., no one can know except my safety net, mutual friends of both partners can know, anyone in the Scene can know, etc.)? 
 

II. ROLES 
 
A. Describe your Sexual orientation (e.g., heterosexual, homosexual, bisexual, polysexual, polyamorous, autosexual, celibate, bi-curious, bi-erotic, bi-playful). 

B. Describe your Scene orientation (e.g., Dominant, Sadist, Top, Master; submissive, masochist, bottom, slave; Switch, Dom-curious, sub-curious, Switch-curious, Fetishist, etc.). 

C. Who will be Dominant in this case? 

D. Who will be submissive in this case? 

E. Is there any chance of switching roles, and If so, when? 
 

III. LOCATION(S) 

A. Meeting place (e.g., hotel, private play party, public dungeon, participant’s home, etc. 

B. Privacy of session (e.g. totally private, Scene spectators okay, public play, “forced” exhibitionism, etc.). 
 
C. Meeting Time (optional for planning a single Scene): 
1. Begin at: 
2. Duration: 
3. Beginning signal: 
4. Ending signal: 
5. Who will keep track of time? 

 
IV. SUBMISSIVE’S MEDICAL INFORMATION 

A. List any prescription medications (e.g., pain medication, birth control, heart medication, antibiotics, anti-depressants, etc.). 

B. List any non-prescription medications taken at the time of the session (e.g., aspirin, pain relievers, cold medication, etc.). 

C. List any and all chronic medical conditions (e.g., asthma, contact lens use, heart/respiratory condition, weak bones/joints, back problems, circulatory problems, high/low blood pressure, epilepsy, fainting spells, diabetes, etc.). 

D. List any surgical implants (e.g., artificial joints, breast implants, penile implants, pacemakers, prosthetics, etc.). 

E. List any Allergies (e.g., foods, pollen, cigarette smoke, medications, fabrics, adhesives, lubricants, etc.). 

F. List any history of  Sexually Transmitted Diseases (e.g. viral hepatitis, HIV, genital herpes, gonorrhea, syphilis, etc.). 

G. List any phobias (e.g., claustrophobia, agoraphobia, acrophobia, etc.). 

H. In case of emergency, contact: 
 

V. DOMINANT’S MEDICAL INFORMATION 
 
A. List any prescription medications (e.g., pain medication, birth control, heart medication, antibiotics, anti-depressants, etc.). 

B. List any non-prescription medications taken at the time of the session (e.g., aspirin, pain relievers, cold medication, etc.). 

C. List any and all chronic medical conditions (e.g., asthma, contact lens use, heart/respiratory condition, weak bones/joints, back problems, circulatory problems, high/low blood pressure, epilepsy, fainting spells, diabetes, etc.). 

D. List any surgical implants (e.g., artificial joints, breast implants, penile implants, pacemakers, prosthetics, etc.). 

E. List any Allergies (e.g., foods, pollen, cigarette smoke, medications, fabrics, adhesives, lubricants, etc.). 

F. List any history of  Sexually Transmitted Diseases (e.g. viral hepatitis, HIV, genital herpes, gonorrhea, syphilis, etc.). 

G. List any phobias (e.g., claustrophobia, agoraphobia, acrophobia, etc.). 

H. In case of emergency, contact: 
 

VI. ETIQUETTE AND OBEDIENCE 
 
A. Will the submissive promptly obey all orders (within the Limits set)? 

B. Should the dominant “overpower” or “force” the submissive to comply with orders (within the Limits set)? 

C. May the submissive verbally resist? 

D. May the submissive physically resist? 

E. May the submissive try to “turn the tables” (i.e. switch roles)? 

F. Should the submissive be “punished” for disobedience or lack of etiquette? 
 
G. The submissive agrees to address the dominant by the following titles (e.g., Sir/Ma’am, Master/Mistress, My Lord/My Lady, etc.). 
 
 
VII. SEXUAL LIMITS AND PREFERENCES 

Use the following codes to indicate your preferences with regards to the following types of play:  0= no opinion, 1= favorite, 2= like it, 3= will do it to please partner, 4= indifferent, 5= dislike it, 6= hard limit (will never do it), ?= no experience with it but curious, != no experience with it but desire it. Also make any notes you feel help describe your preferences with regards to the listed type of play.  All sexual contact is assumed to be within the limits of “safer sex” practices. 
 
A. Anilingus (oral stimulation of anus) 

1. Dominant on Submissive 
2. Submissive on Dominant 

B. Cunnilingus (oral stimulation of clitoris/vagina) 

1. Dominant on Submissive 
2. Submissive on Dominant 

C. Fellatio (oral stimulation of penis) 

1. Dominant on submissive 
2. submissive on Dominant 

D. Kissing 

1. Dominant on submissive 
2. submissive on Dominant 

E. Masturbation (digital stimulation of genitals) 

1. Dominant on submissive 
2. submissive on Dominant 
3. Dominant on self in the presence of the submissive 
4. submissive on self in the presence of the Dominant 

F. Directed Bisexuality (i.e. the Dominant “forces” the submissive to expand their sexual orientation). 

G. Group Sex 

H. Anal intercourse 

I. Multiple Penetration 

J. Vaginal intercourse 

K. Is swallowing of semen acceptable to the submissive? 

L. What type of sex toys may be used on the submissive? 
 
1. anal beads 
2. anal plugs 
3. ben wa balls 
4. dildoes 
5. strap on toys 
6. suction toys 
7. vibrators 
8. other: 

M. Other sexual practices: 
 

VIII. BONDAGE LIMITS AND PREFERENCES 

Use the following codes to indicate your preferences with regards to the following types of play:  0= no opinion, 1= favorite, 2= like it, 3= will do it to please partner, 4= indifferent, 5= dislike it, 6= hard limit (will never do it), ?= no experience with it but curious, != no experience with it but desire it. Also make any notes you feel help describe your preferences with regards to the listed type of play.  For instance, you may desire the use of a Gag, but perhaps only cloth gags, or ‘breathable’ gags. 
 
A. General Bondage Limits 

1. Acceptable degree of immobility/helplessness (i.e., simulated, limited, moderate, extreme) 
2. Acceptable locales (i.e., in private, secluded outdoor settings, discrete public settings, obvious public settings, public dungeons, etc.) 
3. Acceptable time duration (i.e., minutes, an hour, a few hours, 8-12 hours, days) 

B. Parts of Body Bound 
1. Ankles 
2. Ankles to Wrists (i.e. hog-tie) 
3. Arms 
4. Breasts 
5. Elbows 
6. Fingers/Toes 
7. Genitals 
8. Head 
9. Knees 
10. Legs 
11. Wrists (in front, or in back) 
12. Total body bondage (e.g. mummification) 
13. Other: 

C. Bondage Paraphernalia 
1. Blindfolds 
2. Bondage Gloves 
3. Cages (e.g., animal cages, iron maidens, jail cells) 
4. Chains 
5. Chastity Belts or Cock Cages 
6. Collars 
7. Earplugs/Earphones 
8. Fabric (e.g., scarves, nets, tie down straps, fabric cuffs, etc.) 
9. Gags (e.g., ball gags, cloth gags, tape, breath-through gags, etc.) 
10. Handcuffs/Metal shackles 
11. Hoods 
12. Leashes/Leads 
13. Leather Cuffs and/or Straps 
14. Plastic Wrap 
15. Rope 
16. Tape 
17. Spreader bars 
18. Other: 

D. Bondage Techniques 
1. Positioning on command (virtual bondage) 
2. Public Bondage (Exposed or under clothes) 
3. Rope Dresses/harnesses (e.g., Japanese Rope Bondage, German Harnesses) 
4. Suspension (specify; full or partial; upright, inverted, or horizontal 

E. Bondage Equipment (Dungeon Furniture) 

1. Bondage Frame 
2. Bondage Table/Bench 
3. Rack 
4. St. Andrews Cross 
5. Slings/Swings 
6. Spanking Bench 
7. Stocks/Pillory 
8. Turntable 
9. Wheel 
10. Whipping Post 
11. Other: 

F. Bondage Locations 
1. Tied to Bed 
2. Tied to Car Seat 
3. Tied to Chair 
4. Tied to Medical Examination Table 
5. Tied to Sawhorse 
6. Tied to Table 
7. Tied to Tree 
8. Tied to Truck Bed 
9. Tied to Wall 
10. Tied to another submissive 
11. Tied to Other: 
 

IX. PHYSICAL DISCIPLINE LIMITS AND PREFERENCES 

Use the following codes to indicate your preferences with regards to the following types of play:  0= no opinion, 1= favorite, 2= like it, 3= will do it to please partner, 4= indifferent, 5= dislike it, 6= hard limit (will never do it), ?= no experience with it but curious, != no experience with it but desire it.  Also make any notes you feel help describe your preferences with regards to the listed type of play.  For instance, you may desire “Hot Wax Play” but not on your genital area. 

A. Body (bare handed) Discipline Techniques 
1. Anal fisting 
2. Biting 
3. Face slaps 
4. Hair Pulling 
5. Pinching 
6. Scratching 
7. Spanking 
8. Vaginal fisting 
9. Wrestling 
10. Other: 

B. Flagellation (striking with discipline tools) 
1. Canes/Switches 
2. Floggers/Cats 
3. Household Objects: 
a) belt 
b) clothing hanger 
c) fly swatter 
d) hairbrush 
e) oar 
f) ping pong paddles 
g) shoe horn 
h) spatula 
i) ruler 
j) razor strop 
k) switch 
l) wooden spoon 
m) other: 
4. Paddles 
5. Riding Crops 
6. Straps 
7. Quirts 
8. Whips 
9. Other: 
 

C. Pressure Play 
1. Clamps 
a) Genital 
b) Nipple/Breast 
c) weighted 
d) Other areas: 
2. Clothespins 
a) Genital 
b) Nipple/Breast 
c) Zippers (linked clothespins) 
d) Other areas: 
3. Vacuum/Suction Play 
a) Genital 
b) Nipple/Breast 
c) Other areas: 
4. Other: 

D. Temperature Play 
1. Cold Metal 
2. Fire Play 
3. Hot Oil 
4. Ice/Cold Water 
5. Ice Dildoes 
6. Molten Wax/Candle play 
7. Other: 
 
E. Body Modification (specify temporary or permanent where appropriate) 
1. Abrasion 
2. Branding 
3. Corseting 
4. Infibulation 
5. Knife/Edge play 
6. Needle Play 
7. Piercing 
8. Tattooing 
9. Other: 

F. Miscellaneous Techniques 
1. Breath Control 
2. Electrical Play (e.g. static, violet wands, TENS units, etc.) 
3. Other: 
 
 
X. LIMITS AND PREFERENCES ON MARKING 
 
A. Is it acceptable to the submissive if the play leaves some marks? 

B. What kind of marks are acceptable (Specify; none, temporary redness, welts, small bruises, abrasions, scratches, cuts, piercings, etc.) and where on the body  are they permissible? 

1. Arms 
2. Breasts/Chest area 
3. Buttocks 
4. Feet 
5. Genitals 
6. Hands 
7. Midriff/Torso 
8. Neck 
9. Nipples 
10. Legs 
11. Thighs 
12. Upper Back/Shoulders 
13. Other: 

C. Is it acceptable to the submissive if the play breaks the skin or draws small amounts of blood? 
 
D. How easy or difficult has it been to mark the submissive in the past? 
 
 
XI. LIMITS AND PREFERENCES ON MENTAL DICSIPLINE AND HUMILIATION 

Use the following codes to indicate your preferences with regards to the following types of play:  0= no opinion, 1= favorite, 2= like it, 3= will do it to please partner, 4= indifferent, 5= dislike it, 6= hard limit (will never do it), ?= no experience with it but curious, != no experience with it but desire it. Also make any notes you feel help describe your preferences with regards to the listed type of play.  For instance, you may desire to be called a “slave” but perhaps only in a “fond or endearing” tone of voice. 
 

A. The submissive agrees to accept being referred to by the following terms: (e.g., slave, slut, whore, wench, hussy, worm, serf, peon, boy, child, student, pet, toy, etc.). 

B. Clothing Choices (e.g., lingerie, latex clothes, leather clothes, collars, cuffs, costumes,  “slutty” clothing, uniforms, no underwear, etc.) 

C. Enemas 

D. Facial Ejaculation (or on other areas) 

E. Forced Exhibitionism (specify; private, semi-private, Scene audience only, secluded 
outdoor setting, discrete public setting, obvious public setting, etc.) 

F. Forced Fetishism (e.g., foot worship, boot licking, public wetting, etc., etc., etc.) 

G. Forced Profanity (submissive is forced to use “dirty” language) 
 
H. Forced Transvestitism or Cross Dressing 

I. Positioning or Posturing (e.g., kneeling, crawling, serving as furniture, display positions, punishment positions, etc.) 
 
J. Public Obedience Training (specify; private, semi-private, Scene audience only, secluded outdoor setting, discrete public setting, obvious public setting, etc.) 
 
K. Public Sex (specify; private, semi-private, Scene audience only, secluded outdoor setting, discrete public setting, obvious public setting, etc.; and type of sexual activity permissible) 

L. Scat games (e.g., fecalphilia, corophagia, etc.) 

M. Sexual Control (e.g., enforced chastity, sexual denial, sexual performance) 

N. Spitting 

O. Teasing 

P. Verbal “abuse” (e.g. scolding, drilling, profanity, etc.) 

Q. Water Sports (e.g. urolangnia, bladder control games, golden showers) 
 
R. Other: 
 
 
XII. SAFE WORDS/SIGNALS 

Safe words and safe signals are not an option.  They are one of the minimum requirements of safe play.  In some cases, so called “safe scales” may be implemented so that the submissive may indicate to the Dominant the level of intensity they are experiencing.  Safe signals are to be used when the submissive cannot speak (is gagged, hooded, etc.). 
 
A. Hard Stop (the Scene ends completely):    word:  signal: 

B. Stop (current play type stops/pauses):  word:  signal: 

C. Slow (current play type slows or eases up): word:  signal: 

D. Go (current play needs to intensify):  word:  signal: 
 

XIII. ROLEPLAYING GAMES 

Use the following codes to indicate your preferences with regards to the following types of play: 
0= no opinion, 1= favorite, 2= like it, 3= will do it to please partner, 4= indifferent, 5= dislike it, 6= hard limit (will never do it), ?= no experience with it but curious, != no experience with it but desire it. Also make any notes you feel help describe your preferences with regards to the listed type of play.  For instance, you may desire a “Simulated rape scenario” that does not include actual sexual intercourse.  With regards to roleplaying, it is best to be as detailed as possible.  Express your fantasies. 
 
A. Age play/Infantilism 

B. Animal role play  (e.g. pony boy/girl, human puppy/kitty) 

C. Boss and secretary 

D. Clergy and parishioner 

E. Drill instructor and recruit 

F. Evil Magician and captured Prince/Princess 

G. Lord/Lady of Manor and butler/maid 

H. Master/Mistress and slave scenario 

I. Prostitute and John scenario 

J. Scientist and human guinea pig 

K. Simulated incest scenario 
 
L. Simulated kidnapping scenario 
 
M. Simulated rape scenario 

N. Spy/Criminal Interrogation scenario 
 
O. Teacher and student scenario 

P. Warrior/Amazon and slave boy/girl 

Q. Other: (insert your own special fantasy) 
 
 
XIV. OPPORTUNITIES/SPECIAL SKILLS 

A. Is there anything in particular either partner would like to try and explore? 
 
 

B. Are there any unique stories that can be shared?