Block House Application Form

Your City / Country
Indicate the date/s you wish to visit me
Indicate the duration of your visit. e.g 2 hrs; 3 hrs; 12 hrs; 24 hrs etc
Please also indicate if you understand English
What do you want from your session. Be detailed as possible
Please be clear on those practices you do NOT want to engage in
List any medical issues you may have and anything that limits your movement
** If you consent to being filmed, you have the option of wearing a mask. You will need to complete a consent form and provide your ID for age verification.