Scene Negotiation Form

Author: Electric Switch Of The West © 1982 & 1983

Reprinted with permission of the author Electric Switch of the West (pseudonym) 1982,1983 and may not be copied or redistributed. All rights and copyrights reserved by the author. Visit to learn more from the author (and possibly get the current version of the article).

My apologies to Electric Switch Of The West for having this form on my site without permission. My sincere gratitude to her for granting me permission to continue using her work on the site.

Used With Author(s) Permission


 Negotiation for a scene is usually done between play partners the first few times they play. Hence the terms bottom and top are being used in the sample form below. Normaly within a comitted dominant/submissive relationship, negotiating for every scene is not neccessary, though it does take place for special scenes. (example: consentual rape fantasy) Again, this is just one sample, and for informational purposes only. Each person's relationship is different. Though having such a form as a basis for negotiation makes it easier not to forget something and enables better safety with participants who do not know each other extremely well.  - Raven Shadowborne


              Sample Negotiation Form
Answer the questions honestly and openly, for this will help the top in making the bottom's experience wonderful. 

        People Who will take part: 
        Who will watch: 
        Note: The session will involve only those people specify named above. 

    Will any permanent record be made of the session, photo, video, audio?:    {Yes/ No  Explanation:}
2: ROLES: 
       Who will be topt: 
       Who will be bottom: 

             Mistress/Master &Slave 
             Cross-dressing/gender play 
             age play 
             animal play 

4: Any chance of switching roles?   {Yes /No Explanation:} 

       Who will ensure privacy?: 


    Time Begin at: 
        Beginning signal: 
        Ending signal: 
        Who will keep track of time?: 


    Will bottom promptly obey? {Yes/ No Explanation:} 
    May the top "overpower" or  "force" the bottom ? {Yes/ No Explanation :} 
    May the bottom verbally resist? {Yes /No Explanation } 
    May the bottom  physically resist? {Yes /No Explanation } 
    May the bottom try to "turn the tables"? {Yes /No Explanation } 
    Does the bottom agree to wear a collar? {Yes /No Explanation } 
    The bottom agrees to address the dominant by the what title?:
    Bottoms's limits: physical/emotional/SM activity limits: 

    Top's limits: physical/emotional/SM acitivty limits:

    Any problems with the bottom's: 
      Heart   {Yes /No Explanation } 

       Liver {Yes /No Explanation } 

      Lungs {Yes /No Explanation } 

      Neck/Back/Bones/Joints {Yes /No Explanation } 

      Kidneys {Yes /No Explanation } 

      Nervous System/Mental {Yes /No Explanation } 

      Is the bottom wearing contact lenses? {Yes /No Explanation } 

      Does the bottom have implanted pace maker? {Yes /No Explanation } 

      Drug Metering Pumps? {Yes /No Explanation }

    Does the bottom have a history of: 
      Seizures {Yes /No Explanation } 

      Dizzy Spells {Yes /No Explanation } 

      Diabetes {Yes /No Explanation } 

      Hyperglycemia {Yes /No Explanation } 

      Seizures Disorders {Yes /No Explanation } 

      Known Brain Wave Abnormalities {Yes /No Explanation } 

      High Blood Pressure {Yes /No Explanation } 

      Fainting {Yes /No Explanation } 

      Asthma {Yes /No Explanation } 

      Heart Rhythm Oddities {Yes /No Explanation } 

      Hyperventilation attacks {Yes /No Explanation }

    Describe any phobias: 

    Any surgical implants (breast, face, etc.?) 

    Is the bottom taking aspirin? Yes/ No 
    Is the bottom taking ibuprofen, Motrin, or other non-steroidal, anit-infammatory drugs? Yes/ No 
    Is the bottom taking antihistamines? Yes/ No If yes which one? 
    Other medications (and side effects of)  bottom is taking: 

    Allergic to: 
     Bandage tape: {Yes /No Explanation } 
    Nonoxynol-9 {Yes /No Explanation } 
    Latex {Yes /No Explanation } 
    Other allergies: {Yes /No Explanation } 

    In case of emergency notify: 

    Any problems with the top's: 
      Heart {Yes /No Explanation } 

      Liver {Yes /No Explanation } 

      Lungs {Yes /No Explanation } 

      Neck/Back Injuries {Yes /No Explanation } 

      Bones/Joints {Yes /No Explanation } 

      Kidneys  {Yes /No Explanation } 

      Nervous System/Mental {Yes /No Explanation } 

      Heart Rhythm Oddities {Yes /No Explanation } 

      Seizure Disorders {Yes /No Explanation } 

      Implanted Pace Maker {Yes /No Explanation } 

      Drug Metering Pumps {Yes /No Explanation } 

      Known Brain Wave Abnormalities {Yes /No Explanation } 

    Top's other medical conditions: 

    Medications top is taking: {Yes /No Explanation } 

    Is the dominant currently certified in First Aid and CPR: {Yes /No Explanation } 

    Paramedic scissors: Yes/ No 
    Fire extinguisher: Yes/ No 
    First Aid Kit: Yes/ No 
    Blackout lights: Yes/ No 
    Flashlight: Yes/ No 
    Extra Keys to all locks: Yes/ No
Will play take place in an isolated area such as a farmhouse or other location?: Yes/ No 
If yes, what precautions will ensure the submissive's safety if the dominate becomes unconscious? 

13: SEX 

    Are you Male? 
    Are you Female? 
    Are you a TS? 

    Does any participant believe they might have a trichomonas or yeast infection? Yes/ No 
    Does any participant believe they might have herpes?  Yes/ No 
    Does any participant believe they might have any STD? Yes/ No 
    Does any participant believe they might have Hepatitis? Yes/ No 
    Have participants been tested for HIV? Yes/ No 

      Been tested positive? Yes/ No
    Check off which of the following sexual acts are acceptable and state whether it is top to bottom, bottom to top, or both.: 
      Masturbation " " 
      Fellatio " " 
      Cunnilingus " " 
      Rimming " " 
      Anal Fisting " " 
      Vaginal Fisting " " 
      Vaginal intercourse Yes No 
      Anal intercourse " " 
      Is swallowing of semen acceptable?
15: TOYS 
    Will any sex toys such as vibrators, dildoes, butt plugs, ben wa balls, etc be used? Yes/ No 
     If yes, describe them: 

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

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

        The top can use (only) the following intoxicants during the  session: (acceptable and quantity) 

       The bottom can use (Only) the following intoxicants during the session: (acceptable and quantity) 


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

      Hands in front Yes/ No 
      Hands behind 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 
      Tied to bed Yes/ No 
      Use of blindfold Yes/ No 
      Use of gag Yes/ No 
      Use of hood Yes/ No 
      Use of rope Yes/ No 
      Use of handcuffs/metal restraints Yes/ No 
      Use of tape Yes/ No 
      Use of leather cuffs Yes/ No 
      Suspension Yes/ No
    Acceptable degree of immobility/helplessness:  Limited Moderate Extreme Explanation
18: PAIN: 
    Bottom's general attitude about receiving pain: (choose one) Likes Accepts Neutral Dislikes Will not accept 

    Quantity of pain bottom wants to receive: (choose one) None Small Average Large Explanation: 

    Top's general attitude about giving pain:(choose one) Likes Neutral Dislikes 

    Quantity of pain top wants to give:(choose one) None Small Average Large Explanation: 

    The following types of pain are acceptable: 

      Spanking Yes/ No 
      Paddling Yes/ No 
      Whipping Yes/ No 
      Caning Yes/ No 
      Face slaps Yes/ No 
      Biting Yes/ No 
      Nipple clamps Yes/ No 
      Genital clamps Yes/ No 
      Clamps elsewhere Yes/ No 
      Hot creams Yes/ No 
      Ice Yes/ No 
      Hot Wax Yes/ No 
      Other types/methods of pain: Yes/ No If yes: describe
Additional remarks: 

19: MARKS: 

    Is it acceptable to the bottom if the play leaves marks? Yes/ No 
      Visible while wearing street clothes? Yes/ No 
      Visible while wearing a bathing suit? Yes/ No 
      Other: If yes, describe


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

    How easy of difficult has it been to mark the bottom in the past? Yes/ No


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

        The bottom agrees to the following forms of erotic humiliation: 

         "Verbal abuse" Yes/ No 
        Enemas Yes/ No 
        Spitting Yes/ No 
        Water Sports Yes/ No 
        Scat games Yes/ No 
    Any prior really good or really bad experiences in these areas? Yes/ No explanation
        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/ No 
    Safe call set up? Yes/No explain 

        Anything in particular either party would like to try and explore? Yes/ No 

        After the session we need a coming down period. Yes/ No 

        The next day we should discuss how things went. Yes/ No 

        A week later follow-up In case of crisis: Yes/ No 

    Anything Else?

        Top Best Part 1-10 scale(ten tops) : 

        Worst Part 1-10: 

        Most memorable part: 

        1-10 Other comments: 

        Bottom Best part 1-10: 

        Worst Part 1-10 

        Most memorable 1-10 

        Other comments 







Back To General BDSM
E-mail Site Owner
Back To Home Page


Page by: Raven Shadowborne © 2001

Graphics & Buttons by: Aylissa Cair & Raven Shadowborne © 1999 & 2001





LnR Toy Store

Site Map


To hear of changes to the web site, or events taking place in the chat room, enter your e-mail address and click on the button below to join the LnRannounce mailing list. This is an announcement list only and is of very low volume. Or if you prefer, e-mail Raven ( ) to be added to the list, be sure to include your e-mail address and the name of the list within the e-mail.

Subscribe to LnRannounce
Powered by
Link To Domination