Scene Negotiation Checklist

From SM 101 with some changes by others. Used by permission of Jay Wiseman

Not all applies to our scenes, do answer the questions honestly and openly, for this will help me in making your experience wonderful

People

Who will take part?

Who will watch?

(Note: The session will involve only those people specifically named above.)

Will any permanent record be made of the session (photographs, video, audiotapes?

Yes

Explanation:

Roles

Who will be dominant?

Who will be submissive?

Type of scene:

Mistress/Slave

Obedience

Will submissive promptly obey?

Yes

Explanation

May the dominant "overpower" or "force" the submissive?

Yes

Explanation

May the submissive verbally resist?

Yes

Explanation

May the submissive physically resist?

Yes

Explanation

May the submissive try to "turn the tables"?

Yes

Explanation

Does the submissive agree to wear a collar?

Yes

Explanation

The submissive agrees to address the dominant by the following titles:

Limits

Submissive's limits

Submissive's physical/emotional/SM activity limits:

Any problems with the submissive's:

Heart

Yes

Liver

Yes

Lungs

Yes

Neck/Back/Bones/Joints

Yes

Kidneys

Yes

Nervous System/Mental

Yes

Explanation

Is the submissive wearing contact lenses?

Yes

Does the submissive have implanted pace maker?

Yes

Does the submissive have any metal plates implanted?

Yes

Drug Metering Pumps?

Yes

Does the submissive have a history of....

Seizures

Yes

Dizzy Spells

Yes

Diabetes

Yes

Hypoglycemia

Yes

Seizures Disorders

Yes

Known Brain Wave Abnormalities

Yes

High Blood Pressure

Yes

Fainting

Yes

Asthma

Yes

Heart Rhythm Oddities

Yes

No Explanation

Hyperventilation attacks

Yes

Describe any phobias:

Submissive's medical conditions: Any surgical implants (breast, face, etc?)

Yes

Explanation

Is the submissive taking aspirin?

Yes

Is the submissive taking ibuprofen, Motrin, or other non-steroidal, anti-inflammatory drugs?

Yes

Is the submissive taking antihistamines?

Yes

Other medications submissive is taking:

Allergic to;

Bandage tape:

Yes

Nonoxynol-9

Yes

Other allergies:

In case of emergency notify:

Dominant's Limits

Any problems with the dominant's:

Heart-

Yes

Liver

-Yes

Lungs

-Yes

Neck/Back Injuries

Yes

Bones/Joints

Yes

Kidneys

Yes

Nervous System/Mental-

Yes

Heart Rhythm Oddities-

Yes

Seizure Disorders

Yes

Implanted Pace Maker-

Yes

Drug Metering Pumps-

Yes

Does the Dominant have any metal implants?

Yes

Known Brain Wave Abnormalities-

Yes

Dominant's other medical conditions:

Medications dominant is taking:

Is the dominant currently certified in First Aid and CPR-

Yes

Safety gear on hand: Paramedic scissors:

Yes

Fire extinguisher:

Yes

First Aid Kit:

Yes

Blackout lights:

Yes

Flashlight:

Yes

Will play take place in an isolated area such as a farmhouse or other location?:

Yes

If yes, what precautions will ensure the submissive's safety if the dominate becomes unconscious?

. Sex

Are you Male?

Yes

Are you Female?

Yes

Are you a TS?

Yes

if yes- pre-op

Yes

post-op

Yes

Age:

Marital/Relationship Status:

Monogamous:

Sneaking behind partners back:

Polyamory:

Occupation:

Height:

Weight:

Hair Color:

Eye Color:

Facial Hair?

Characteristics (things you'd like known about you, physically):

Does any participant believe they might have a trichomonas or yeast infection

Yes

Explanation:

Does any participant believe they might have herpes?

Yes

Explanation:

Does any participant believe they might have any STD?

Yes

Explanation:

Does any participant believe they might have Hepatitis?

Yes

Explanation:

Have participant been tested for HIV?

Yes

Been tested positive?

Yes

Explanation:

Check off which of the following sexual acts are acceptable:

Masturbation

Dominant to Submissive

Submissive to Dominant

Fellatio

Dominant to Submissive

Submissive to Dominant

Cunnilingus

Dominant to Submissive

Submissive to Dominant

Rimming

Dominant to Submissive

Submissive to Dominant

Anal Fisting

Dominant to Submissive

Submissive to Dominant

Vaginal Fisting

Dominant to Submissive

Submissive to Dominant

Vaginal intercourse

Dominant to Submissive

Submissive to Dominant

Anal intercourse

Dominant to Submissive

Submissive to Dominant

Is swallowing of semen acceptable

Yes

Will any sex toys such as vibrators, dildoes, butt plugs, ben wa balls, etc be used?

Yes

Describe:

Which of the above activities will involve birth control pills, diaphragms, spermicidal suppositories, lubricants containing nonoxynol-9, or contraceptive foam/suppositories/gel?

Which of the above activities will involve condoms, gloves, dental damns, and/or other barriers?

Intoxicants

The dominant can use (only) the following intoxicants during the session:

Acceptable quantity:

The submissive can use (Only) the following intoxicants during the session:

Acceptable quantity:

Bondage

The submissive agrees to allow (only) the following types of bondage:

Hands in front

Yes

Hands behind

Yes

Ankles

Yes

Knees

Yes

Elbows

Yes

Wrists to ankles (hog-tie)

Yes

Spreader bars:

Yes

Tied to Chair

Yes

Tied to bed

Yes

Use of blindfold

Yes

Use of gag

Yes

Use of hood

Yes

Use of rope

Yes

Use of handcuffs/metal restraints

Yes

Use of tape

Yes

Use of leather cuffs

Yes

Suspension

Yes

Acceptable degree of immobility/helplessness:

Limited

Moderate

Extreme

Explanation

Pain

Submissive's general attitude about receiving pain:

Likes

Accepts

Neutral

Dislikes

Will not accept

Quantity of pain submissive wants to receive:

None

Small

Average

Large

Explanation:

Dominant's general attitude about giving pain:

Quantity of pain dominants wants to give:

None

Small

Average

Large

Explanation:

The following types of pain are acceptable:

Spanking

Yes

Paddling

Yes

Whipping

Yes

Caning

Yes

Face slaps

Yes

Biting

Yes

Nipple clamps

Yes

Genital clamps

Yes

Clamps elsewhere

Yes

Locations:

Hot creams

Yes

Locations:

Ice

Yes

Locations:

Hot Wax

Yes

Locations:

Other types/methods of pain:

Additional remarks:

Marks

Is it acceptable to the submissive if the play leaves marks?

Yes

Visible while wearing street clothes?

Yes

Visible while wearing a bathing suit?

Yes

Other:

Is it acceptable to the submissive if the play draws small amounts of blood?

Yes

Explanation:

How easy of difficult has it been to mark the submissive in the past?

Erotic Humiliation

The submissive agrees to accept being referred to by the following terms:

The submissive agrees to the following forms of erotic humiliation:

"Verbal abuse"

Yes

Enemas

Yes

Spitting

Yes

Water Sports

Yes

Scat games

Yes

Other:

Any prior really good or really bad experiences in these areas?

Safe Words

Safe Words #1 and its meaning

Safe word #2 and its meaning

Safe word #3 and its meaning

Non-verbal safe words and their meaning

Will "two-squeezes" be used?

Yes

Opportunities/Special Skills

Anything in particular either party would like to try and explore?

Dominant

Which statement best suits you:

I live D/s lifestyle every day in most activities:

I live D/s lifestyle frequently when in relationship:

I live D/s lifestyle occasionally in relationship:

I live D/s lifestyle in "scenes" or "play" only:

I use D/s only in "scenes" or "play":

I do not live D/s lifestyle but would with correct sub:

I would not live D/s lifestyle but would use for "play" with correct sub

(Other statement which best suits you):

Are you interested in:

On-Line Relationship ONLY:

On-Line/Phone Relationship ONLY:

Real Time Relationship ONLY:

On-Line/Phone/Real Time Relationship Combination:

Do you currently have a sub/slave:

Are you currently seeking a sub/slave:

Would you take on "multiple subs":

Can or would you travel to meet/be with a sub:

Would you have a sub travel to meet you:

Are you experienced with:

On-Line D/s:

Phone D/s:

Real Time D/s:

Previous Relationships:

Have you ever had a "collared" sub:

On-Line Only:

Real Time:

(Why did that relationship terminate, current relationship with that sub

D/s SOCIAL:

Would you expect a sub to perform the following and if so, how often:

(Rating scale: "O" (occasionally). "F" (frequently). "A" (at all times when applicable).

Kneeling (clothed):

Kneeling (naked):

Wearing bondage outside "scenes" (crotch ropes, etc.):

Wearing toys outside "scenes" (nipple clamps, etc.):

Wearing toys/bondage in public:

"Correct posture" outside "scenes" (define):

Sexual situations in public:

Wearing D/s collar in public:

Wearing D/s collar in private:

Performing "instructions" (delivered on-line or phone):

Would you require a standard form of dress for the sub in private (if so, what):

Would you require a standard form of dress for the sub in public (if so, what):

What form of address would you expect from the sub for yourself and others (check applicable):

Yourself:

Sir:

Master:

First name:

Mr. (last name):

Mistress

Ma'am

Domina

First Name

Ms (last name)

Other Males:

Other Females:

Both Dom/Dommes and subs...in and out of BDSM

What aspects of your subs' life would you want to control (check all applicable):

Choice of clothing:

Choice of food:

Daily activities:

Special occasion activities (non-sexual):

Sexual activities:

Social contacts:

Sleeping hours:

Bathing/toilet rituals:

Business/professional life:

Would you desire to "share" your sub with others:

Yes

(If "YES", state the circumstances and likely other partners)

Would you wish your sub to have any of the following (check applicable):

Tattoo of ownership:

Branding of ownership:

Collar (or bracelet) worn constantly:

Screen name change to reflect ownership:

List any "scene" or "play" activities which you WOULD NOT DO under any circumstances:

PUNISHMENTS:

What forms of punishments would you use on a disobedient sub:

Writing assignments:

Meditation:

Corporal Punishment (spanking, whipping, etc.):

Bondage (any form):

Removal of privileges:

Loss of Contact with you:

Withholding orgasms/pleasure:

Other (please state):

REWARDS:

What forms of rewards would you give a pleasing sub:

Small "presents" (flowers, etc.):

Extra privileges:

Additional "play":

Personal mementos (inc. letters to her, etc.):

More about you:

Non-D/s Interests/Hobbies:

Favorite Music Types:

Favorite Reading:

Favorite Non-D/s Leisure Time Activities:

Any other information you would like to supply regarding yourself:

Submissive

Which statement best suits you:

I live D/s lifestyle every day in most activities:

I live D/s lifestyle frequently when in relationship:

I live D/s lifestyle occasionally in relationship:

I live D/s lifestyle in "scenes" or "play" only:

I use D/s only in "scenes" or "play":

I do not live D/s lifestyle but would with correct Dom:

I would not live D/s lifestyle but would use for "play" with correct Dominant:

(Other statement which best suits you):

Are you interested in:

On-Line Relationship ONLY:

On-Line/Phone Relationship ONLY:

Real Time Relationship ONLY:

On-Line/Phone/Real Time Relationship Combination:

Do you currently have a Dom/Top/Owner:

Are you currently seeking a Dom/Top/Owner:

Can or would you travel to meet/be with a Dominant:

Are you experienced with:

On-Line D/s:

Phone D/s:

Real Time D/s:

Previous Relationships:

Have you ever been collared?

Why did that relationship terminate? What's your current relationship

with that Dominant?

Have you had previous relationships:

Real life:

Only On Line:

What aspects of your life would you want your Dominant to control (check all the apply)

Choice of clothing:

Choice of food:

Daily activities:

Special occasion activities (non-sexual):

Sexual activities:

Social contacts:

Sleeping hours:

Bathing/toilet rituals:

Business/professional life:

Would you desire to be "share" with others:

Yes

Shared with:

Female Dominates:

Female submissives:

Male Dominants:

Male submissives:

Would you have any of the following done for your Dominant:

Check those that apply

Tattoo of ownership:

Branding of ownership:

Collar (or bracelet) worn constantly:

Screen name change to reflect ownership:

List any "scene" or "play" activities which you WOULD NOT DO under any circumstances:

More about you:

Non-D/s Interests/Hobbies:

Favorite Music Types:

Favorite Reading:

Favorite Non-D/s Leisure Time Activities:

Any other information you would like to supply regarding yourself:

Follow-Up After the session we need a coming down period The next day we should discuss how things went A week later follow-up In case of crisis: 18. Anything Else?

Post-session notes:

Dominant

Best Part 1-10 scale (ten tops)

Worst Part 1-10

Most memorable part 1-10

Other comments:

Submissive

Best part 1-10

Worst Part 1-10

Most memorable 1-10

Other comments

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(This is a form that should be filled out by both dom(me) and sub...it gives you both a starting place) Please answer these question completely honestly. Please use a separate sheet/s of paper if necessary.

What sexual fantasies have you had that relate to s/m?

What is it about yourself that attracts you to the s/m play scene? Describe a scene you would find to be highly erotic, satisfying and descriptive of the role you wish to assume in s/m.

Describe a scene you would fine completely out of bounds or off limits as far as your current disposition and understanding are concerned.

List erotic toys and devices you currently own.

It is recommended that both parties also fill out the BDSM Submissive Check List as a way to better understand each other's interests.

Disclaimer: By filling this form out and returning it, I am doing so with full knowledge and with a competent mind. It is my understanding that the form is used for social purposes only and for my benefit. I also understand that the persons or persons who are to be handling the form will do so with confidentiality and with no malicious intent. I am stating that I am over the consenting age of the state that I live in and I am an adult. By submitting this form I release all liability and do so at my own risk.

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