Submission Form
This is your opportunity to introduce yourself to Me.
Name
*
First Name
Last Name
Anything you like to be called?
Sissy names, scene name, pet names, etc.
Phone Number
*
I will never call w/o permission. No Google Voice or App numbers!
Email
*
Make sure this is correct & check your spam folder!
Where did you find Me?
*
Please Select
Dickie Virgin
Eros
FetLife
Tryst
SinSearch
Other?
Where would you like to see Me?
*
Please Select
Incall - DC Region
Philadelphia
Hotel Incall +150
Hotel Outcall +175
Travel
Suggest 3 dates & times for your first session
*
Which level are you seeking?
*
Please Select
Red Label
Black Label
Gold Label
The Executive
Couples Retreat
Length of Session
I am interested in a custom training plan - 3 to 5 sessions
Yes
No, just the one
I haven't decided
Are you interested in approaching kink from an intuitive healing perspective?
Please Select
That's exactly why I'm here 😊
Possibly..?
Just whips & chains for me!
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Next
Now some information about your session...
Please select the areas you are interested in exploring
Ball Busting/CBT
Bondage
Corporal Punishment/Impact Play
Degredation
Foot Worship
Golden Shower
Humiliation
Massage/Body Worship
Pegging
Sensory Play
Smoking
Smothering
Tickling
WAM
Wax
Other
Rank your top 5 choices from your selections above and add any notes you would like to include.
Madame walks into the room, which styles inspire your submission
Comfy - Yoga pants, the like
Casual - Jeans & T Shirt
Professional
Easing into Domme... Dommesque
Full Glam Domme
Whatever She damn well pleases (the only correct answer, obviously)
Other
Limits - Bodily fluids and extreme play are assumed limits unless stated as kinks
No marks
No marks lasting more than a day
No name calling
Other
Any past injuries, surgeries, or current allergies?
Include any other notes about yourself, your interests & limits, or questions you have for Me.
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Next
I understand that respect and discretion are required of me at all times.
Yes, Madame
No
I have thoroughly read Your website and am prepared to submit.
Yes, Madame
No
I understand that no appointment will be held until I have successfully completed the application process and pay my deposit
Yes, Madame
No
I understand that the requests I am making have potential to cause harm or injury. By choosing to engage in with this somatic practice, I acknowledge and freely accept this risk, releasing Madame Lenora from all liability.
Yes, Madame
No
Submit
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