The purpose of this survey is to get your views on how important you feel it is to gain further insights about intimacy after illness. Your comments are confidential and individual responses will not be shared with anyone.

* 1. If you or your partner has experienced a serious illness that disrupted your love life, please indicate which illnesses had an impact on you:

* 2. How important is it for you to learn more about reigniting intimacy and sexuality after illness:

* 3. Do you and/or your partner find it difficult to openly discuss sexual intimacy issues? How might I help you?

* 4. What three intimacy issues or questions concern you most?

* 5. Would you like to learn more about my intimacy coaching at this time? Please enter your first name and email address in the Comments area below if you want me to contact you for a thirty-minute, complimentary break-through Intimacy Discovery Session to help you achieve the level of physical, emotional and spiritual intimacy you want in your life.

* 6. If you would like to be entered in a drawing to win a free copy of my intimacy home study course, “Ten Strategies for Reigniting Sexuality and Intimacy After a Major Illness,” please enter your first name and email address below:

Thank you for responding to this questionnaire!