1. PEOPLE:	
Who (only) will take part?		
Who (only) will watch? 		
Will any permanent record (photographs, audiotapes, videotapes, etc.) be made of the session?	Yes	
	
No	

Put X beside Yes or No	
Explanation		
Bottom’s safety measures, e.g. calls to a friend		

2. ROLES:	
Who will be dominant?		
Who will be submissive?		
Type of scene: 
	
Any chance of switching roles?	Yes	
	
No	

	
Explanation:	
Will the submissive promptly obey? 	Yes	
	
No	

	
Explanation:	
May the dominant "overpower" or "force" the submissive?	Yes	
	
No	

	
Explanation:	
May the submissive verbally resist?	Yes	
	
No	

	
Explanation:	
May the submissive physically resist?	Yes	
	
No	

	
Explanation:	
Does resistance equal a "strong yellow"?	Yes	
	
No	

	
Explanation:	
May the submissive try to "turn the tables:?	Yes	
	
No	

	
Explanation:	
Does the submissive agree to wear a collar?	Yes	
	
No	

	
Explanation:	
The submissive agrees to address the dominant by the following title(s):		

3. PLACE:	
Location:		
Who will ensure privacy?		

4. TIME:			
Begin at: 	Length:		
Beginning signal:			
Ending signal:			
Who will keep track of time?			
 
5. OOPS:	
Does everybody involved understand that there is some risk of accident, miscommunication, misperception, and/or unintentional injury?	Yes	
	
No	

	
Does everybody involved agree to discuss any mishaps in a constructive and non-blaming manner?	Yes	
	
No	

	
 
6. LIMITS:	
Submissive's limits: Any problems with the submissive's	
heart:	
Yes	
	
No	

	lungs:	
Yes	
	
No	

	kidneys:	
Yes	
	
No	

	
neck/back:	
Yes	
	
No	

	bones/joints:	
Yes	
	
No	

	liver:    	
Yes	
	
No	

	
nervous system:	
Yes	
	
No	

	mental:	
Yes	
	
No	

		
Explanation:	
Is the submissive wearing contact lenses?	Yes	
	
No	

	
Does the submissive suffer from carpal tunnel syndrome or any related problems?	Yes	
	
No	

	
Does the submissive have a history of	
seizures:	
Yes	
	
No	

	dizzy spells:	
Yes	
	
No	

	blood pressure:	
Yes	
	
No	

	
diabetes:	
Yes	
	
No	

	fainting:	
Yes	
	
No	

	asthma:    	
Yes	
	
No	

	
hyperventilation attacks	
Yes	
	
No	

		
Explanation:	
Describe any phobias:	
Submissive's other medical conditions:
	
Any surgical implants (breast, face, etc.)?	Yes	
	
No	

	
Is the submissive taking aspirin?	Yes	
	
No	

	
Is the submissive taking ibuprofin, Aleve, or other non-steroidal, anti-inflammatory drugs?	Yes	
	
No	

	
Is the submissive taking antihistamines?	Yes	
	
No	

	
Other medications the submissive is taking:	
Is the submissive allergic to	
bandage tape:	
Yes	
	
No	

	Other allergies:	
In case of emergency notify:		

Dominant's limits: Any problems with the Dominant's	
heart:	
Yes	
	
No	

	lungs:	
Yes	
	
No	

	kidneys:	
Yes	
	
No	

	
neck/back:	
Yes	
	
No	

	bones/joints:	
Yes	
	
No	

	liver:    	
Yes	
	
No	

	
nervous system:	
Yes	
	
No	

	mental:	
Yes	
	
No	

		
Explanation:	
Does the Dominant have a history of	
seizures:	
Yes	
	
No	

	dizzy spells:	
Yes	
	
No	

	blood pressure:	
Yes	
	
No	

	
diabetes:	
Yes	
	
No	

	fainting:	
Yes	
	
No	

	asthma:    	
Yes	
	
No	

	
hyperventilation attacks	
Yes	
	
No	

		
Explanation:	
Dominant's other medical conditions:	
Other medications the Dominant is taking:	
In case of emergency notify:	
Is the dominant currently certified in First Aid and CPR?	Yes	
	
No	

	
Safety gear on hand	
paramedic scissors:	
Yes	
	
No	

	flashlight:	
Yes	
	
No	

	first aid kit:	
Yes	
	
No	

	
blackout light:	
Yes	
	
No	

	fire extinguisher:	
Yes	
	
No	

	

	
Will the play be in an isolated area such as a farmhouse?	Yes	
	
No	

	
If yes, what will ensure the submissive's safety if the dominant becomes unconscious?	
no bondage to chair/bed/etc.:	
Yes	
	
No	

	third person present:	
Yes	
	
No	

	telephone/radio/panic button within submissive's reach:	
Yes	
	
No	

	
no gag:	
Yes	
	
No	

	silent alarm:	
Yes	
	
No	

		
Other:
7. SEX:	
Does any participant believe they might have a sexually transmitted disease?	Yes	
	
No	

	
Explanation:	
Does any participant believe they might have herpes? Note: herpes takes many forms and generally only the genital form is of concern.	Yes	
	
No	

	
Explanation:	
Have participants been tested for HIV?	Yes	
	
No	

	
Has any participant tested positive?	Yes	
	
No	

	
Explanation:	

which of the following sexual acts are acceptable:	
Masturbation: dominant to submissive 	Yes	
	
No	

	
Masturbation: submissive to dominant	Yes	
	
No	

	
self-masturbation by submissive	Yes	
	
No	

	
self-masturbation by dominant	Yes	
	
No	

	
Oral: dominant to submissive	Yes	
	
No	

	
Oral: submissive to dominant	Yes	
	
No	

	
Analingus: dominant to submissive	Yes	
	
No	

	
Analingus: submissive to dominant	Yes	
	
No	

	
Vaginal fisting: 	dominant to submissive	Yes	
	
No	

	
Vaginal fisting: 	submissive to dominant	Yes	
	
No	

	
Anal fisting: 	dominant to submissive	Yes	
	
No	

	
Anal fisting: 	submissive to dominant	Yes	
	
No	

	
Vaginal intercourse: 	dominant to submissive	Yes	
	
No	

	
Vaginal intercourse: 	submissive to dominant	Yes	
	
No	

	
Anal intercourse: 	dominant to submissive	Yes	
	
No	

	
Anal intercourse: 	submissive to dominant	Yes	
	
No	

	
Is swallowing semen acceptable?	Yes	
	
No	

	
Is any participant menstruating?	Yes	
	
No	

	
Will sex toys such as vibrators, dildos, butt plugs, etc. be used?	Yes	
	
No	

	
If yes, describe:
	
Which of the above activities will involve birth control pills, diaphragms, spermicidal suppositories, lubricants containing nonoxynol-9, or contraceptive foams/suppositories/gels?
	
Which of the above activities will involve condoms, gloves, dental dams, and/or other barriers?

8. 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:	
Explanation:	

9. BONDAGE:	
The submissive agrees to allow (only) the following types of bondage...		
hands in front:	Yes	
	
No	

	
hands behind back:	Yes	
	
No	

	
ankles:	Yes	
	
No	

	
knees:	Yes	
	
No	

	
elbows:	Yes	
	
No	

	
wrists to ankles (hog-tie):	Yes	
	
No	

	
spreader bars:	Yes	
	
No	

	
tied to chair:	Yes	
	
No	

	
use of blindfold:	Yes	
	
No	

	
use of gag:	Yes	
	
No	

	
use of hood:	Yes	
	
No	

	
use of rope:	Yes	
	
No	

	
use of tape:	Yes	
	
No	

	
use of leather cuffs:	Yes	
	
No	

	
use of handcuffs/metal restraints:	Yes	
	
No	

	
suspension:	Yes	
	
No	

	
mummification with plastic wrap, body bag, or similar technique:	Yes	
	
No	

	
Any past bad experiences by either person with bondage, gags, blindfolds, and/or hoods?	Yes	
	
No	

	
Explanation:	

10. PAIN:	
Submissive's general attitude toward receiving pain:	likes	

accepts	

neutral	

dislikes	

not accept	

	
Quantity of pain the submissive wants to receive:	none	

small	

average	

large	

	
Explanation:	
Dominant's general attitude toward giving pain:	likes	

will give	

neutral	

dislikes	

will not give	

	
Quantity of pain the dominant wants to give:	none	

small	

average	

large	

	
Explanation:	
Will the "now" technique be used?	Yes	
	
No	

	
Explanation:	
Will the "one to ten" technique be used?
Explanation:	Yes	
	
No	

	
The following types of pain are acceptable...	
spanking	Yes	
	
No	

	
paddling	Yes	
	
No	

	
flogging	Yes	
	
No	

	
caning	Yes	
	
No	

	
face slaps	Yes	
	
No	

	
hair pulling	Yes	
	
No	

	
biting	Yes	
	
No	

	
nipple clamps	Yes	
	
No	

	
genital clamps	Yes	
	
No	

	
clamps elsewhere	Yes	
	
No	

	
Locations:	
ice	Yes	
	
No	

	
hot wax	Yes	
	
No	

	
tickling	Yes	
	
No	

	
Other types/methods of pain:
Additional remarks:

11. MARKS:	
Is it acceptable to the submissive if the play leaves marks?	Yes	
	
No	

	
Visible while wearing street clothes?	Yes	
	
No	

	
Visible while wearing a bathing suit?	Yes	
	
No	

	
Is it acceptable to the submissive if the play draws small amounts of blood?	Yes	
	
No	

	
Explanation:	
How easy or difficult has it been to mark the submissive in the past?

12. 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	
	
No	

	
enemas:	Yes	
	
No	

	
forced exhibitionism:	Yes	
	
No	

	
spitting:	Yes	
	
No	

	
water sports:	Yes	
	
No	

	
scat games:	Yes	
	
No	

	
Other:	
Any prior really good or really bad experiences in these areas?	Yes	
	
No	

	
Explanation:

13. SAFEWORDS	
Safeword # 1 and its meaning:
	
Safeword # 2 and its meaning:
	
Safeword # 3 and its meaning:
	
Non-verbal safewords and their meaning:

14. OPPORTUNITIES/SPECIAL SKILLS	
Anything either party would especially like to try or explore?

15. AFTERCARE	
What aftercare does the bottom prefer?

	
What aftercare does the top prefer?

	

16. FOLLOW-UP	
Who will initiate contacts?	After the session:	

The next day:	

A week later:	

In the event of a crisis:	

	
Acceptable methods	Email	
Yes	
	
No	

	

Text	
Yes	
	
No	

	

Phone	
Yes	
	
No	

	

In Person	
Yes	
	
No	

	

Other:	

	

17. ARE THERE ANY CONCERNS ABOUT CONFIDENTIALITY/SHARING OF EXPERINCES?
By default, no pictures or recordings will be shared without the approval of all parties.	

18. ANYTHING ELSE?	

What will become of this form after the session?

POST-SESSION NOTES AND FEEDBACK	
Dominant’s overall feeling about the session on a scale of one-to-ten (ten tops)	
Best part of the session and on a scale of one-to-ten how good was it?
	
Worst part of the session and on a scale of one-to-ten how bad was it?
	
Other comments:
	
Submissive’s overall feeling about the session on a scale of one-to-ten (ten tops)	
Best part of the session and on a scale of one-to-ten how good was it?
	
Worst part of the session and on a scale of one-to-ten how bad was it?	
Other comments:

NEGOTIATION SHORT FORM
1.	People
2.	Roles
3.	Place
4.	Time
5.	Oops
6.	Limits
7.	Sex
8.	Intoxicants
9.	Bondage
10.	Pain
11.	Marks
12.	Humiliation
13.	Safewords
14.	Opportunities
15.	Aftercare 
16.	Follow-Up
17.	Confidentiality
18.	Anything Else?

1.	People
1.	Who are participating?
2.	Roles
1.	Who is Top? Bottom? 
2.	What kind of scene? Will Bottom obey readily or resist?
3.	Venue/safety – safety equipment, first aid, safety calls from bottom to friend, etc.
4.	Time and Length
5.	Oops
1.	Does everybody involved understand that there is some risk?
6.	Medical limitations of both Bottom and Top
1.	Physical, mental, medication-related
7.	Sex
1.	Oral, penetration, touch. Discuss this area very, very thoroughly and don’t deviate!!!!!
2.	What protection to be used?
8.	Intoxicants
1.	How much and of what is allowed before and after?
9.	Bondage
1.	What parts of the body? 
2.	What kinds of bondage – rope, tape, gags, blindfolds, etc.?
10.	Pain
1.	How much pain does the bottom want?
2.	Types of pain – spanking, flogging, caning, paddling, electrical, etc.?
11.	Marks
1.	Are marks allowed – street clothes, bathing suits?
12.	Humiliation
1.	Allowed verbal terms, e.g. whore, slut, bitch?
2.	Physical – hair pulling, face slapping, spitting?
13.	Safewords
1.	For example, Green, Yellow, Red
14.	Opportunities – anything special the bottom wants to try?
15.	Follow-Up 
1.	Aftercare for the bottom and for the top
2.	Communication after the scene – hours, days and by whom
3.	How will sub drop be handled?
16.	Anything Else, e.g. confidentiality?

TOP _____________________ BOTTOM ______________________ Date ______________