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 allowed, 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. 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. 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 www.bdsm-education.com to learn more from
the author (and possibly get the current version of the article).
1: PARTICIPATION:
Who will be topt: Who will be bottom: 3: TYPE OF SCENE: 4: Any chance of switching roles? {Yes /No Explanation:} 5: LOCATION 6: DATE AND TIME:
Length: Ending signal: Who will keep track of time?: 7: OBEDIENCE:
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?:
Top's limits: physical/emotional/SM acitivty limits:
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 }
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 } Any surgical implants (breast, face, etc.?) Is the bottom taking aspirin? Yes/ No Allergic to: In case of emergency notify:
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 } Medications top is taking: {Yes /No Explanation } Is the dominant currently certified in First Aid and CPR: {Yes /No
Explanation }
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 Female? Are you a TS? Does any participant believe they might have a trichomonas or yeast
infection? Yes/ No
Fellatio " " Cunnilingus " " Rimming " " Anal Fisting " " Vaginal Fisting " " Vaginal intercourse Yes No Anal intercourse " " Is swallowing of semen acceptable?
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) 17: BONDAGE The bottom agrees to allow (only) the following types of bondage:
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
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:
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
Ice Yes/ No Hot Wax Yes/ No Other types/methods of pain: Yes/ No If yes: describe 19: MARKS:
Visible while wearing a bathing suit? Yes/ No Other: If yes, describe
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:
Enemas Yes/ No Spitting Yes/ No Water Sports Yes/ No Scat games Yes/ No Other: 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
Anything in particular either party would like to try and explore? Yes/ No
Bottom: 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
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 |
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