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This survey is being conducted in connection to a book on dating and relationships that will be published in early 2024.  Answer all questions as honestly as you can. If you are not comfortable answering a question, feel free to skip it.

DISCLAIMER: The responses included in the publication will be reported mostly in percentages and categories based on the results of the survey.  However, if a name is mentioned to illustrate a concept, it will be only a first name, profession, and location of residence, i.e., David a tech specialist in San Francisco, California.

If you would prefer that your real first name is not used, please provide in the space indicated, a “fake” or alias name to use for publication purposes. 

For additional questions, contact Danielle by email at: danielle@butterflypublication.com

NOTE:  To thank you for your participation, a $5 Starbucks gift card will be sent to your email address within 4 to 6 weeks of receipt of the completed survey.

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* 1. What is your first and last name?

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* 2. What is your city and state of residence?

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* 3. What is your email address?

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* 4. What is your phone number?

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* 5. What is your age range?

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* 6. What is your profession?

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* 7. Were you previously married?

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* 8. Do you have children? If so how many?

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* 9. What are the children age range?

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* 10. Do you believe in or practice any religion? Which one?

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* 11. Which race/ethnicity best describes you? (Please choose only one.)

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* 12. What alias or "fake name" would you prefer to use for publication purposes?

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