My Personalized Poem Request Form
Please complete the form below to assist us in designing a personalized poem for you. At the end of the form, there will be a calendar for you to select a time you are available for us to discuss this request with you. A standard poem is $15 and comes with at minimum 9 lines (e.g. 3 stanzas with 3 lines each), a colored background and in digital format. Payment is not due until after we review and finalize your request. Thank you for your interest!
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Who is this poem for?
*
Myself
Spouse
Child
Mother
Father
Grandmother
Grandfather
Other Family
Friend
Someone Special
Other
What is the name of the person receiving the poem?
If the poem is for you, type your name or the name you would like to use.
In which media type would you like your poem?
*
Digital
Non-Digital (Additional fee dependent on final request)
The $15 standard poem comes in digital form. Physical poem prints are an additional cost. Cost varies depending on media selected and number copies requested.
Would you like more than 9 lines in your poem?
*
No, I would like 9 lines.
Yes, I would like more than 9 lines.
The $15 standard poem comes with at least 9 lines. (e.g. 3 stanzas that include 3 lines each). Additional lines may be an extra fee. Fee varies depending on the number of additional lines requested.
Would you like a background image for your poem?
*
Color
Image (+$5)
The $15 standard poem comes with a colored background. An image in the background is an additional fee of $5.
When you were a child, what did you want to be when you grew up?
*
If this poem is not for you, describe the recipient's childhood or type "Not sure.".
What was your favorite thing to do as a child?
*
If this poem is not for you, describe the recipient's favorite thing from the past or type "Not sure.".
What was your favorite subject in high school?
*
If this poem is not for you, describe the recipient's favorite subject in high school (or college) or type "Not sure.".
Would you rather go running or go kickboxing?
*
Running
Kickboxing
Other
If you could change the color of the sky from blue to any other color, what would it be?
*
If this poem is not for you, describe the recipient's favorite color or type "Not sure.".
Would you rather watch Netflix for an hour or watch the Sunset for an hour?
*
Watch Netflix
Watch Sunset
Other
What thoughts come to your mind when you see the phrase "I want to meditate"?
*
If this poem is not for you, describe how the recipient makes you feel special.
If you had $10 million dollars in your savings, what would you do with it?
*
If this poem is not for you, describe how you would treat the recipient if you had $10M dollars.
If you had the power to change the world, what would you change to?
*
If this poem is not for you, describe how you would like to make the recipient's life better and/or what makes them happy.
Would you rather be friends with a jaguar or be friends with an owl?
*
Jaguar
Owl
Other
Is there a sound in silence?
*
Yes
No
Other
What is consciousness?
*
If this poem is not for you, describe how you believe the recipient would respond to the question or type "Not sure."
Poem Request Review Session
*
Submit
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