Thank you for your interest in our state-of-the-art care center. Please fill out the below form to request admittance into one of the finest mental health facilities you could commit to!
Are you the person applying for admittance?
If not, name of person to be admitted:
Birthdate of person for admittance:
Where did you hear of our site?
What do you think of our site?
It's my favorite site
I like it
Are You Kidding?
A little too whacked for my taste
This page proves you need therapy
It REALLY sucks
Favorite part of the site:
Least favorite part of the site:
What's your Damage? (reason for admittance):
Are you willing to get in at ANY price?
Could you sign over all your belongings and firstborn child upon admittance?
Is the person applying easily brainwashed and hypnotized?
Annual Income of Applicant:
What color room would you like?
A Nice Depressing Grey
What should we serve for dinner tonight?
What would you like on your Tombstone?
Reservation for the smoking or non-smoking section?
Reservation for drinking or non-drinking section?
Reservation for sedated or non-sedated section?
Reservation for straightjacket or non-straightjacket section?
How much wood would a woodchuck chuck if a woodchuck could chuck wood?
Would you like fries with that?
Why or Why Not:
Now where to?