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"Live Close, Visit Often" Survey
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1
. Your Name:
Your Name:
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2
. Address:
Address:
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3
. Phone number:
Phone number:
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4
. Email Address:
Email Address:
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5
. Your age:
Your age:
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6
. Are you currently:
Are you currently:
Married
Divorced
Widowed
Single by Choice
7
. If you are not now married, have you ever been married?
If you are not now married, have you ever been married?
No
Yes. How many times?
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8
. Do you want to be:
Do you want to be:
Married
In a Committed Relationship
Neither
9
. If you are not interested in being married, please take a few minutes to tell us why you feel this way. Select all that apply.
If you are not interested in being married, please take a few minutes to tell us why you feel this way. Select all that apply.
Value Independence
Fear of Caregiving
Other. Please explain:
10
. If you are not married, do you want a relationship? Why?
If you are not married, do you want a relationship? Why?
Yes
No
Please tell us why:
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11
. How is your attitude toward marriage different than your mother's?
How is your attitude toward marriage different than your mother's?
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12
. May we contact you for additional comments?
May we contact you for additional comments?
Yes
No
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