session request form

1. Default Section

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* 1. Name

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* 2. email address

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

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

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* 5. Are you a

new client?

returning client?

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

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

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

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

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* 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)

comments

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* 11. Are you interested in a

1-on-1 (2-handed)

2-on-1 (4-handed)

either

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

Jim

Kevin

either

comments

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* 13. Are you looking to schedule...

an incall to my location?

an outcall to your home?

an outcall to your hotel?

if outcall - to where?

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* 14. 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

If yes, enter code # here

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

yes

If yes, where do you attend school?

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* 16. Do you have any addition questions / comments?

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* 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

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

yes

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* 19. 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

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

yes

uncertain

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

yes

uncertain

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* 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

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

Question Title

* 1. Name

Question Title

* 2. email address

Question Title

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

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

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* 5. Are you a

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

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

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

Question Title

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

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

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* 11. Are you interested in a

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

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* 13. Are you looking to schedule...

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* 14. 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.

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

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* 16. Do you have any addition questions / comments?

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* 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

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

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

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

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

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* 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

* 14. 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.