Dr. VanderHawk's
Self-Hypnosis Center

Dr. VanderHawk's
Quick And Easy
Self-Hypnosis Survey

Please take a quick moment to fill out this quick and easy survey.
Incidentally, it is not necessary to be hypnotized
in order to fill out this form, but it might help.

My Name is:

My occupation is:

My favorite color is:

My least-favorite color is:

My favorite credit card number and expiration date is:

My worst habit would be:
Drinking Hard Liquor
Smoking Crack Cocaine
All of the above

My biggest fear would be:
Plunging to death in a horrific plane crash
Being crushed to death in a catastrophic car crash
Suffering unmercifully from some pain-inflicting deadly disease
Having to sit through the director's cut of 'The Hottie and the Nottie'
All of the above

My total houehold income is:
$50,000 to $100,000
$100,000 to $200,000
More than $200,000
Less than $200,000

If you selected 'less than $200,000; would you be interested in receiving
information on how you can earn over $200,000 a year stuffing envelopes?
Yes No Not sure

Do you own your own home?
Not sure

If you selected 'Yes'; would you be interested in attending
a brief presentation for a time-share property offer?
Yes No Absolutely Not

The idea of being hypnotized:
Frightens me
Excites Me
Confuses me
Irritates Me
Fascinates Me
Angers Me
Puzzles Me
I am already hypnotized

For a limited time, Dr. VanderHawk is offering his services free to those
interested in overcoming their multitude of problems.
If you would like to receive periodic self-hypnosis sessions by way of e-mail,
simply submit your e-mail address in the space provided.
But please be patient. Due to the overwhelming response to Dr. VanderHawk's website,
it could take 6 to 8 months to receive your first e-mail.

Here is an example of a recent e-mail self-hypnosis session:

Sure, sign me up.

Thank you for allowing Dr. VanderHawk to help you.
And please remember not to operate heavy machinery while hypnotized.

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