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Alternate Perceptions Magazine, February 2015

UFO Close Encounter/Entity Experiencer Questionnaire Survey Form

by: Brent Raynes

Please copy and paste this form to an email to This email address is being protected from spambots. You need JavaScript enabled to view it., entering your responses with information requested; yes/no answers, and additional details where needed to better explain matters.

I. General background information:

Tel. #:
Date of Birth:
Racial/ethnic background:
Marital status:
Highest year of schooling completed:
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
Right or left handed
Anxiety attacks
Suicidal thoughts; impulses
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
Belief in reincarnation
Past life recollections
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?

Monday, February 26, 2024