Enter Your Information Below Question Title * 1. What is your name? Question Title * 2. What is your age? Under 18 18-30 31-40 41-50 51-60 61-70 70-80 80+ Question Title * 3. What is your current relationship status? Question Title * 4. What is your occupation? Question Title * 5. Where are you based? (City and country) Question Title * 6. Please describe your experience with Erectile Dysfunction (E.D.) Question Title * 7. How long have you had E.D.? Question Title * 8. What other methods of tackling E.D. have you tried, if any? Question Title * 9. Why do you see therapy as an important way of tackling E.D.? Question Title * 10. How has E.D. impacted your life, relationships and confidence? Question Title * 11. If you ended E.D. today what would it mean to you and how would it change your life? Question Title * 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? Less than $100 $100-$1k 1-4k 4-10k 10k+ Question Title * 13. Do you have any other questions or comments you would like to add? Question Title * 14. What’s your best e-mail address (Gary will use this to arrange the call if you’re a good fit)? Question Title * 15. Please re-confirm your e-mail address below Question Title * 16. What's the best phone number to contact you on? (Optional) Question Title * 17. What's your skype address? (Optional) Done