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* 1. What is your name?

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* 2. What is your age?

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* 3. What is your current relationship status?

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* 4. What is your occupation?

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* 5. Where are you based? (City and country)

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* 6. Please describe your experience with Erectile Dysfunction (E.D.)

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* 7. How long have you had E.D.?

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* 8. What other methods of tackling E.D. have you tried, if any?

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* 9. Why do you see therapy as an important way of tackling E.D.?

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* 10. How has E.D. impacted your life, relationships and confidence?

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* 11. If you ended E.D. today what would it mean to you and how would it change your life?

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* 12. If you knew with absolute certainty that therapy would help end your ED and give you the sex life you always wanted, what would that be worth to you?

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* 13. Do you have any other questions or comments you would like to add?

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* 14. What’s your best e-mail address (Gary will use this to arrange the call if you’re a good fit)?

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* 15. Please re-confirm your e-mail address below

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* 16. What's the best phone number to contact you on? (Optional)

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* 17. What's your skype address? (Optional)

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