Gumball Poetry's Psychic Book Questionaire

The Psychic Book Survey

Name

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 it here...

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!