If you wish to remain anonymous (even from me) then feel free to put down "anonymous" or leave a name that will only mean something to yourself personally. If on the other hand you'd like to discuss your responses with me, or refer to it in future, leave your name and contact details in the "Further Information" box at the end.
Please fill out this form as honestly and openly as possible to best indicate the kind of induction and hypnotic play you wish to experience. Though there are some darker and edgier words in the list, these are only for the people for whom darker play is an attraction.
Thanks again for checking this out.