session request form Survey

1. Name

Name

2. email address

email address

3. Telephone number (optional) - (area code) 123-4567

Telephone number (optional) - (area code) 123-4567

4. In which city are you requesting a private session or to attend a workshop(s)

In which city are you requesting a private session or to attend a workshop(s)

5. Are you a

Are you a new client?

returning client?

6. If you are a returning client, approximate date of your last session

If you are a returning client, approximate date of your last session

7. If you are a returning client please list any other email addresses / screen names / etc that you might have used

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

8. What days / dates do you prefer to schedule your session? (Please list in order of preference)

What days / dates do you prefer to schedule your session? (Please list in order of preference) 1.
2.
3.
4.
5.
6.
7.

9. What time(s) of day do you prefer to schedule your session? (Please list in order of preference)

What time(s) of day do you prefer to schedule your session? (Please list in order of preference) 1.
2.
3.
4.
5.
6.
7.

10. What length of a session are you interested in scheduling (check all that apply)?

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)
comments

11. Are you interested in a

Are you interested in a 1-on-1 (2-handed)

2-on-1 (4-handed)

either

12. If requesting a 1-on-1 (2-handed) session, do you prefer?

If requesting a 1-on-1 (2-handed) session, do you prefer? Jim	Kevin	either
comments

13. Are you looking to schedule...

Are you looking to schedule... an incall to my location?	an outcall to your home?	an outcall to your hotel?
if outcall - to where?

14. Do you wish to apply any special discount / coupon offer(s) to your session?

Do you wish to apply any special discount / coupon offer(s) to your session? yes	no
If yes, enter code # here

15. Are you currently a full-time student (with a current, valid student ID)?

Are you currently a full-time student (with a current, valid student ID)? yes	no
If yes, where do you attend school?

16. Do you have any addition questions / comments?

Do you have any addition questions / comments?

17. 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

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

18. I agree to the CANCELLATION AND "NO SHOW" POLICY as outlined on the website

I agree to the CANCELLATION AND "NO SHOW" POLICY as outlined on the website yes

19. how do you prefer to pre-pay for your session?

how do you prefer to pre-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 is pre-paid by a previously purchased certificate

I prefer NOT to pre-pay for my session and wish only to be placed on the "standing list" in case of a cancellation

20. I am interested in the Friday evening workshop "Introduction to Massage"

I am interested in the Friday evening workshop "Introduction to Massage" yes

uncertain

21. I am interested in the "Getting In Touch With Yourself and Others" weekend workshop

I am interested in the "Getting In Touch With Yourself and Others" weekend workshop yes

uncertain

22. 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

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 yes, keep me on your mailing list

If this would be your first time requesting a private session with me or one of my partners, or if it has been longer than 12 months since your last session with me, please complete the responses to my "Preliminary Questionnaire" located at (copy and paste the following link into your browser)

http://www.surveymonkey.com/s.aspx?sm=Jy5FF7OoAD83ru4HUK60Kw_3d_3d

session request form
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session request form
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