Please complete and submit the following form for any mild to severe butt hurtedness.

Name *

First

Last

Email *

Date / Time

Date

Time

Phone

What caused the butthurt?

• Somebody said something
• Someone posted something
• Offensive picture or comment

(check out Reason(s)

Were tears involved?

• Yes
• No

Will you be able to move past it?

• Yes
• No

Reason(s) for filling out the report (check all that apply)

• I am an idiot
• I am a whinner
• I am thin-skinned
• I am a little bitch
• I want my Mommy
• I felt picked on
• I'm better than everyone else
• I'm a righteous asshole
• It wasn't my joke
• No one liked my selfies today
• Life just isn't fair
• Complaining makes me feel better

I think someone will actually care about this?

• Yes
• No

REALLY??

• Yes
• No

After pressing Submit, generously apply the following...

No of tissues needed?

Therapist needed?

• Yes
• No

Submit