Commit Yourself
be in-sane @ in-nyc

All information will be held in strictest confidence, unless of course, we think it is really funny and want to embarrass you in front of your friends, your mom, and the guy who sells you the gerbils.

Official Committal Form

First Name:

Last name

Telephone Number:

Address:

E mail:

URL:

Insanity Checklist

Do you suffer from any of the following?

Check all that apply

Paranoid delusions	Unnatural love of Ed Wood movies
Pyromania	Manic depression
Homicidal tendencies	Stigmata or the Wounds O'Christ
Schizophrenia	Excessive desire to peel beer labels
Suicidal fantasies	Extreme hatred of puppies and kitties
Angora or other fetish	Belief you are God or Bill Gates
Dementia	Delusions of Adequacy
Obsessive-compulsive disorder	Nymphomania or sexual excess
Necrophilia	Love of Barry Manilow tunes

Do not write below this line.

For Doctors' use only

Recommended Treatment

Shock Therapy	Sexual Therapy
Lobotomy	Spanking
Drug Therapy	Too Sick/Danger to Society and Self

We accept all major credit cards, cash, jewelry, drugs, and first born male child for payment.