Dating Questionnaire Step 1 of 5 20% Please take the time to complete this questionnaire. This will give me the opportunity to learn more about you, but more importantly, it will allow you to learn about yourself. This will enable you to have a better perspective, and therefore more meaningful relationships with others. The whole purpose of our relationship together is to put you in the position of meeting the right person for you. So take your time, be honest, and enjoy the process! (All information collected is confidential.)About YouName* First Last Gender*MenWomenAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Age*Occupation*Marital Status*SingleDatingDating ExclusivelyMarriedSeperatedDivorcedDo you have children?*YesNoAge of children (if applicable) What are you looking for?What do you want to get out of working with me?*What do you want out of your relationships?*More dates? Someone to have sex with? A potential marriage partner?Describe the type of person you are attracted to.*Describe the type of person you want to meet. Close your eyes. When you have a clear picture, begin writing. Don't skip any details, because this is your description of your ideal partner.Describe the type of person you are.*Describe who you are. Be honest as you list all your positive and negative traits. Make sure you describe what you think you look like. It is important to know yourself intimately so you can attract the type of partner you want.Describe the type of person you attract.*Over the next two weeks, instead of looking at people that are attracted to you, start noticing the people who are looking at you. Because chemistry between two people is a key ingredient to a successful relationship, this exercise will allow you to see if the people that you are attracted to are also attracted to you.Describe the type of person others think you are.*Ask five people of the opposite sex what type of image you project. Be sure to take detailed notes so you can get a complete picture of the image you project, so you can compare it to what you THINK you project.How do you go about meeting others?*Make a list of all the ways and/or places you try to meet the opposite sex over the course of a one-month period. Use a scale of 1 to 5 (1=poor, 5=excellent) to rate each way/place.Describe your daily routine.*Write in detail your daily routine. In this routine, do you see people you want to talk to often? Write down a description of one of these people you want to meet. This will allow you to train your mind to let such a person come into your life.Describe the excuses you make.*Write down ALL of the excuses ("reasons") you use that prevent you from approaching the people you are interested in meeting. Dating / RelationshipsHow many dates do you go on in a one-month period?*Please enter a number less than or equal to 999.How many of these are blind dates?*Please enter a number less than or equal to 999.How do you feel about those numbers?*How many dates do you WANT to go on in a one-month period?*Do you use the internet to date?*NoYesWhat percentage (%) of the date time do you talk about yourself (vs. listening to the other person)?*How many of the dates (or what %) do you exchange phone numbers?*When do you typically ask for the phone number?*How quickly do you call after getting a phone number? How quickly do you call back?*After the first date, how long do you wait to ask for a second date?*What is the "perfect" (ideal) first date? Where would you like to go or be taken?*How often do you have "casual" sex?*How many dates do you go on before you have sex with that person?*What is the most bizarre place you have met someone that you dated? How many dates did you go on with that person?*Where would you like to meet more people?*When are you more comfortable meeting someone for the first time?*In a group settingBy myselfHow many serious relationships have you had?*12345678910More than 10How long have your serious relationships lasted?* Do you continue to search even if you are dating someone you like?*NoYesHow long has it been since your last relationship?*Have you ever been married or lived with a partner?*NoI've lived with a partnerI've been marriedWhat kind of pattern do your previous relationships tend to have? How have they ended?*What is usually your role in the relationship?* Your ImageThis section will allow me to understand how you feel about yourself.Do you consider yourself successful? What is your definition of success?*Do you consider yourself happy or fulfilled? If not, what is missing?*Do you like your wardrobe? What do you like/dislike about it?*Do you feel good about your body? Why or why not?*Do you like your hair? Why or why not?*Do you like your height? Why or why not?*Do you have good friends? Who is your best friend? Why is that person your best friend?*Who do you go to for relationship advice? How helpful have you found their advice to be?*If you could change one thing about yourself, what would it be?*Where do you like to be seen? Why?*Do you consider yourself approachable? Why or why not?*Do you consider yourself a generous person? Why or why not?*Do you think you are a good listener? Why or why not?*How quickly do you judge others?*How well do you take criticism?*Do you consider yourself romantic? Give an example of a time where you were romantic?*Do you think you are a good lover? Why or why not?* Your FeedbackAs we continue to work together, I would like to make this as productive as possible for you.Please let me know what other areas you think would be helpful to explore.*PhoneThis field is for validation purposes and should be left unchanged.