Welcome! 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!

Name:


E-mail Address:


Are you the person applying for admittance?
Yes
No

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 Absolutely Stellar I like it It's Okay 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?
Yes
No

Could you sign over all your belongings and firstborn child upon admittance?
Yes
No

Is the person applying easily brainwashed and hypnotized?
Yes
No

Annual Income of Applicant:


What color room would you like?
Blue Red Yellow Green Black Orange Purple Puece Mauve Pink Lime Peach Chartreuse Turquoise Dirt Brown Institutional Seafoam A Nice Depressing Grey

What should we serve for dinner tonight?


Favorite Quote:


What would you like on your Tombstone?


Reservation for the smoking or non-smoking section?
Smoking
Non-smoking

Reservation for drinking or non-drinking section?
Drinking
Non-drinking

Reservation for sedated or non-sedated section?
Sedated
Non-sedated

Reservation for straightjacket or non-straightjacket section?
Straightjacket
Non-straightjacket

How much wood would a woodchuck chuck if a woodchuck could chuck wood?


Other Comments:


Would you like fries with that?
Yes
No

Why or Why Not:

Now where to?

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