Sexual Consent Form
&
Right of Privacy Agreement
I, _______________________, hereby declare under penalty of
perjury that I am over 18 years old.
I further declare that this agreement is of my own free will and that neither I nor anyone near or dear to me has been threatened with harm or embarrassment.
Both parties agree that this is a private agreement not to be disclosed to third parties except in case of accusation of sexual misconduct by (name)
________________________ of (state)___________________. If he/she shows or makes
public this agreement without accusation of sexual misconduct, it is agreed that he/she will be liable for damages for invasion of privacy, whether or not his/her signature appears herein.
By initialing __________________, agrees to engage in all or some of the following
consensual acts. Check boxes below and initial the following.
Sexual fondling, petting and kissing________
Sexual intercourse________
Oral copulation (mutual)________
Unilateral copulation by________only.
Other, to be specified:
________________________________________________________________________
________________________________________________________________________
I further declare that I am at this time not under the influence of alcohol, drugs or medication and agree to engage in consensual sex with____________________________
and intend not to change my mind before the sex act is over. However, it is further understood that if I, for any reason say the words “Code Red,” that my partner agrees to stop instantly.
Signed:_________________________Signed:__________________________
Date:___________________________Date:____________________________
Check with your attorney before entering into any agreement.
© Dr. Ava Cadell, Clinical Sexologist, 2003
Website: www.avacadell.com Email: drava@avacadell.com
