This is the BDSM Scene Consent Form for High-Risk Scenes that I personally use. I rely on it before engaging in any type of edge play, intense impact, medical or breath play, psychological scenes, or anything that carries a significant risk of physical, emotional, or psychological harm. It helps me ensure that all negotiations are clear, that safety and consent are prioritized, and that everyone involved feels respected, informed, and empowered.
PARTICIPANT INFORMATION
Dominant/Top Name:
Submissive/Bottom Name:
Scene Date:
Scene Location:
INFORMED CONSENT DECLARATION
☐ I understand the nature of the high risk activities proposed in this scene.
☐ I am entering into this scene of my own free will and under no coercion.
☐ I affirm that I am mentally and emotionally capable of giving informed consent.
☐ I understand I may revoke my consent at any time, for any reason.
TYPE OF HIGH-RISK PLAY INVOLVED
(Check all that apply)
☐ Breath Play / Erotic Asphyxiation
☐ Knife Play / Cutting
☐ Blood Play / Needles / Medical Play
☐ Fire Play
☐ Electro Play (e.g., Violet Wand, TENS)
☐ Psychological Edge Play (Fear, Degradation, CNC Themes)
☐ Heavy Impact / Whipping
☐ Bondage (Rope/Metal/Enclosure/Immobilization)
☐ Temperature Play (Ice/Wax/Extreme Heat)
☐ Sensory Deprivation
☐ Anal Play or Fisting
☐ Humiliation / Mindfuck / Emotional Play
☐ Other (Specify):
LIMITS AND BOUNDARIES
Hard Limits (Absolutely NO):
Soft Limits (Negotiate with caution):
Triggers or Trauma to Avoid:
Medical Conditions / Allergies / Safety Considerations:
SAFEWORDS & NON VERBAL SIGNALS
Safeword (to stop scene completely):
Slowdown Word (to pause or check in):
Nonverbal Signal (if gagged or unable to speak):
☐ Tap hand 3 times
☐ Drop object
☐ Snap fingers
☐ Other:
AFTERCARE PLAN
Aftercare Needs (physical/emotional):
☐ Water/Snacks
☐ Quiet time
☐ Warm blanket
☐ Cuddles
☐ Verbal reassurance
☐ Debriefing/Processing
☐ Other:
Duration Needed:
Anything to Avoid After Scene:
NEGOTIATION NOTES (Scene Outline)
Describe the planned scene in reasonable detail:
Include: agreed intensity, words/phrases to avoid, intentions, power dynamic themes, props used, tools/toys involved, public/private setting, and duration.
IN CASE OF EMERGENCY
Top’s Emergency Contact Name & Number:
Bottom’s Emergency Contact Name & Number:
First Aid Kit Available:
☐ Yes
☐ No
Phone Charged & Nearby:
☐ Yes
☐ No---
SIGNATURES & AGREEMENT
By signing below, we affirm that we have openly discussed this scene, understand all associated risks, and voluntarily consent to engage in it together. We agree to stop or adjust the scene if consent is revoked or safety is compromised.
Dominant/Top Signature: Date:
Submissive/Bottom Signature:
Date:
This document does not replace communication, intuition, or responsibility. We always follow RACK, or PRICK.