Chapter One — BLACKOUT

t w e n t y o n e

First Name

Last Name

Phone Number

Birthday

Address

City

State

Zip Code

Emergency Contact + Phone # + Relationship To You

Choose your current time zone?

Card Number

CVC

Billing Address

Billing Address 2

Billing City

Billing Country

Billing State

Billing Zip

Enter Your Billing Information

Do you have epilepsy?

Do you have asthma?

Any physical impairments?

What are your daily rituals?

Over what do you obsess?

Describe, in detail, how your obsessions manifest themselves?

How much control do you have over your obsessions?

Does being around other people make you nervous?

Would you consider yourself to be a paranoid person?

Sitting up at night, alone, and the room is dark...what scares you?