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The Psychic Book Survey


Name
email
Street Address
City
State
Zip Code

Age 0-10 11-14 15-16 17-19 20-24
25-31 32-41 42-49 50-58 59-64
65-75 76-85 86-109 110+

What's your favorite color?

Describe your prevailing moods or states of being over the past month. (Pick up to three).
Passionate Happy Snarly Euphoric
Giddy Sad In Love Artsy
Lucky Genius Ignoramus Dreamy
Naive Horny Aerodynamic Cunning
Mischievous Naughty Evil Holy
Flighty Feeble Fragile Far Away
Angry Itchy Breakdown Break Dance
Punch Drunk Embarrassed Irritable High Roller
Fearless Roller Coaster Excited Murderous
Smart Ass Sassy Saucy Moldy
Hip Treading Water Stick in the Mud Stinky
Other:


Now choose the three moods or states of being that you'd like to feel over the next month or so.
Passionate Happy Snarly Euphoric
Giddy Sad In Love Artsy
Lucky Genius Ignoramus Dreamy
Naive Horny Aerodynamic Cunning
Mischievous Naughty Evil Holy
Flighty Feeble Fragile Far Away
Angry Itchy Breakdown Break Dance
Punch Drunk Embarrassed Irritable High Roller
Fearless Roller Coaster Excited Murderous
Smart Ass Sassy Saucy Moldy
Hip Treading Water Stick in the Mud Stinky
Other:


What type of reading have you been doing lately?

What's your sign?

What are the names of your pets, or if you don't have pets, your imaginary friends.

What's your favorite type of commotion or natural disaster?

Is there anything that you would like to add, any information that would help our team of experts dive into the psychic world, grapple with the great literary foes, and resurface with your perfect, psychic book?



Write out a check for $15 and make it out to "Gumball Poetry". Pop it in the mail
Gumball Poetry
PO Box 15278
Portland, OR 97293
and hit the SUBMIT button.


When we receive your check
we'll get your psyche rolling
in no time with your very own
Psychic Book Prescription!




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