Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
How would you like me to contact you?
*
No Preference
Email
Text Message
City of Residence
*
Employer & Position / Title
*
What interests would you like to explore and/or, what are some turn ons?
*
The more details the better.
What are your boundaries?
*
Any health concerns or conditions I should be aware of?
*
How experienced are you?
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Very new
Some experience (privately)
Some experience (with a professional)
Very experienced
What is your pain tolerance?
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No pain please!
Mild
Moderate
High
Very High
How about leaving marks on your body?
*
None
Some temporary are fine (hours to a day or so)
Temporary, but leave a good impression!
I want to see your marks for a long time.
Mark me painfully and permanently!
Tell me a little about yourself:
*
Preferred Session Location?
*
Bucktown Dungeon
West Town Dungeon
Logan Square Dungeon
Date and Time Requested?
*
My availability varies. If you are flexible, or have more than one date in mind, feel free to include those additional options. Note that while it is not completely impossible, I am very rarely available with less than 24 hours notice.
Session Duration?
*
1 Hour
1.5 Hours
2 Hours
2.5 Hours
3+ Hours (for sessions of 3 hours or longer, please expand on this preference in the "date and time" section)
How did you find me?
*
Are there any providers you would like to list as references?
If so, please include their name and contact information, along with anything else you would like me to know about them. Adding provider references will also expidite your screening.
Request Form Acknowledgement
*
I acknowledge and understand that upon my session request being approved, I will be required to submit one or all of the following IDs for screening and verification: Government issued ID (only name and photo need to be visible), workplace ID showing your name, photo, and employer, and/or a selfie of yourself holding your chosen ID. I also acknowledge that submitting a request does not guarantee I will be approved for a session.
Deposit for First Time Clients
*
I acknowledge and understand that, upon my first session request being approved, I will be required to make a one time, non-refundable $100 deposit for my session. This deposit will be applied toward my full tribute amount after confirmed session scheduling.
Your request has been received.
Please allow 1-3 days for my response, and check your spam folder in the event my reply to you is sent there (it has been brought to my attention this happens from time to time).
Forms submitted more than once (and not by accident) will be ignored.