Exit this survey session request form5 1. Default Section Question Title * 1. Name Question Title * 2. email address Question Title * 3. Telephone number (optional) - (area code) 123-4567 Question Title * 4. In which city are you requesting a private session or to attend a workshop(s) Question Title * 5. Are you a new client? returning client? Question Title * 6. If you are a returning client, approximate date of your last session Question Title * 7. If you are a returning client please list any other email addresses / screen names / etc that you might have used 1 2 3 4 5 Question Title * 8. What days / dates do you prefer to schedule your session? (Please list in order of preference) 1. 2. 3. 4. 5. 6. 7. Question Title * 9. What time(s) of day do you prefer to schedule your session? (Please list day and then time in order of preference) 1. 2. 3. 4. 5. 6. 7. Question Title * 10. What length of a session are you interested in scheduling (check all that apply)? INTRODUCTORY (1 hour) BASIC (1 1/2 hours) EXTENDED (2 hours) ADVANCED (3 hours) EUPHORIA (4 hours) comments Question Title * 11. Are you interested in a 1-on-1 (2-handed) 2-on-1 (4-handed) 3-on-1 (6-handed) 4-on-1 (8-handed) any available comments Question Title * 12. Are you looking to schedule... an incall to my location? an outcall to your home? an outcall to your hotel? if outcall - to where? Question Title * 13. Do you wish to apply any special discount / coupon offer(s) to your session?*PLEASE NOTE* Special discounts / coupons can only be applied to sessions scheduled (and confirmed) a minimum of 24 hours in advance. yes no If yes, enter code # here Question Title * 14. Are you currently a full-time student (with a current, valid student ID)? yes no If yes, where do you attend school? Question Title * 15. Do you have any addition questions / comments? Question Title * 16. by my initials here and by checking the appropriate box below, I agree to the CANCELLATION AND "NO SHOW" POLICY as outlined on the website Question Title * 17. I agree to the CANCELLATION AND "NO SHOW" POLICY as outlined on the website yes no Question Title * 18. how do you prefer to pay for your session? pre-pay by personal check or money order sent via USPS (must be received no later than 7 days after your session request is approved) pre-pay using PayPal.com (must be paid within 7 days of the PayPal invoice date) this session fee is covered by a previously purchased or received certificate I prefer to pay cash at the time of my session (only available to sessions scheduled in the Twin Cities) I prefer NOT to pre-pay for my session and wish only to be placed on the "standing list" in case of a cancellation Other (please specify) / comments Question Title * 19. I am interested in the Friday evening workshop "Introduction to Massage" yes no uncertain Question Title * 20. I am interested in the "Getting In Touch With Yourself and Others" weekend workshop yes no uncertain Question Title * 21. I am not interested in scheduling a session or attending a workshop at this time, but wish to remain on your mailing list to be notified of upcoming sessions / workshops in my area.Note: you will be send an invitation via my mail server iContact.com asking you to confirm your acceptance to be added to my contact list for your area. yes, keep me on your mailing list no, do not send me any future mailings or notifications Question Title * 22. If this is your first session with me / us or if it has been longer than 6 months since your last session with me / us, it will be greatly helpful if you could take a few moments to complete our "Preliminary Questionnaire" (see link below)Your responses would better enable me / us to tailor your session to your own particular needs and experiences and help to make your session a much more personalized and enjoyable experience.Please check the appropriate box below. I have had a session with you within the past 6 months and have previously completed my "Preliminary Questionnaire" I had a session with you but it has been longer than 6 months ago and need to update my responses to my "Preliminary Questionnaire" This will be my first session with you and I have already submitted my "Preliminary Questionnaire" responses. This will be my first session with you and I will be submitting my "Preliminary Questionnaire" responses after I complete this session request form Question Title * 23. here is the link to the "Preliminary Questionnaire" (click on the link below - will open in a new window) "Preliminary Questionnaire" Done
