Alternate Perceptions Magazine, February 2015
UFO Close Encounter/Entity Experiencer Questionnaire Survey Form
by: Brent Raynes
I. General background information:
Name:
Address:
Email:
Tel. #:
Male:
Female:
Date of Birth:
Racial/ethnic background:
Marital status:
Highest year of schooling completed:
Occupation:
Special training, interests, abilities, or hobbies:
II. In your own words, please provide some details of what your UFO experience(s) were or have been about:
III. Psychological and Paranormal aspects of your life. Have you experienced any of the following? (Please feel free to give detailed information in addition to Yes and No responses)
Head injury
Severe electric shock
Struck by lightning
Effects upon electrical equipment
Déjà vu
Premonitions
Right or left handed
Anxiety attacks
Depression
Insomnia
Suicidal thoughts; impulses
Dyslexia
Amnesia
Synesthesia (multiple sensing)
Out-of-body experiences
Poltergeist experiences
Psychokinesis (mind-over-matter)
Rapport with animals
Psychic sensitivity non-existent, increased, the same, or first appeared at
time of UFO experience(s)?
Ghost encounter
Angel encounter
Near-death experience
Telepathy
Belief in reincarnation
Past life recollections
Meditation
Hypnosis
If you have ever been hypnotized, were you a bad, fair, good, or excellent subject?
Please feel free to describe any other aspect(s) that you have experienced, that you feel may be related, that were overlooked in the above areas:
How do you feel that your experience(s) have ultimately impacted your life? What have been the positive/negative elements for you?
