Rope Session Intake Form

First name*

Last name*

Your email*

Pronouns*

Birthdate*

Social media handle(s)*

Please list a rope/kink reference or how you found me:*

Do you have health insurance?*

Yes

Emergency contacts*

Are there parts of your body that you do not want to be touched or stimulated?*

Are there parts of your body where you are experiencing pain currently or chronically?*

What types of touch do you like/dislike? Examples include caresses, scratches, squeezes, pinches, tickles, impact, etc.*

Do you have any medical conditions or take any medications that could impact your experience in rope? Examples include treatment for allergies, asthma, diabetes, low or high blood pressure, nerve conditions and seizures.*

What is your understanding of the risks of rope bondage? How do you assess your personal risk profile?*

What is your knowledge of and experience with nerve anatomy as it applies to rope? Have you ever had a nerve injury?*

Are you aware of any trauma or triggers you have that could be activated by being in bondage or other forms of kinky play?*

If you have a heavy emotional or physical reaction to being in rope, what type of support would you like me to provide?*

Is there anything else I should know regarding your preferences about your body in rope?*

What feelings, colors, emotions, experiences or dynamics are you looking for in rope?*

Are there other kinky activities you are interested in adding to a rope scene?*

Describe your experience with rope/kink and your consent/negotiation practices.*

What are your safe words/actions?*

What are your hard limits/boundaries? Examples include "no rope on my feet" or "don't put a blindfold on me."*

What are your soft limits/boundaries? Examples include "check-in before any inversions" or "no impact play until I ask for it."*

What are your "fuck yeahs?" (Elements of rope or other kinks you enjoy/want to try)*

Have you had your boundaries crossed, consent violated or been harmed while engaging in rope/kink? Please explain.*

Have you crossed boundaries, violated consent or caused harmed while engaging in rope/kink? Please explain.*

What are your aftercare needs and wants?*

Were any of these questions difficult to answer? If so, please explain.*

By submitting this form, you agree to the following statements: -I am over the age of 21. -I understand the dangers associated with rope bondage and have decided they are within my risk profile. -Everything I have shared in this form is true to me, my experience, and what I am looking for. -If anyone experiences harm during our session, I will partake in an accountability/mediation process.*

Yes

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I agree to have pictures/videos of me taken during the session.*

Yes

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I agree to having my pictures/videos shared on social media.*

Yes

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Please use this section to ask any questions or add any additional information.

Rope Session Intake Form

Kemo Burns

KEMOBURNS@GMAIL.COM

https://linktr.ee/kemoburns

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