Personal Information:

First Name: Last Name:
Address:
City:
State:
Zip Code:
Daytime Phone: Type:
Evening Phone: Type:
Best Time to Call:
Email Address:
Gender:
Age:
Education:
Occupation:
Annual Income:
Marital Status: How long:


Your Current Social Situation: (*Check all that apply)

I am new to the area I'm really busy with work
I do not feel comfortable asking people out I meet a lot of people, just not the right type


Preferred Characteristics About The Person You Are Seeking:

Age range: to:
Education:
Occupation:
Location:
Marital Status:


How are you meeting people now?

Friends/Family Online Church
Bars/Nightclubs Work Chance


What, if any, issues have you encountered when using an online dating site?

Inaccurate Profiles Safety Concerns People wanting to play games
Misleading Photos Not everyone was single No singles in my local area


How comfortable do you feel about speaking with a relationship expert?