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., Susan, an HR manager and Jeff, a fireman, in Houston, Texas.

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

Note: For the purpose of facilitating this survey, the man will be referred to as "husband" or "male partner" and the woman as "wife" or "female partner" regardless of marital status.

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

NOTE:  To thank you for your participation, a $10 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 the husband/male partner first and last name?

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* 2. What is the wife/female partner first and last name?

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

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* 4. What is your email address?

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* 5. What is your phone number?

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* 6. What is your age range (man)?

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* 7. What is your age range (woman)

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* 8. What are your professions?

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* 9. What is your current marital status?

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* 10. How long have you been together as a couple?

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

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* 12. What are the children age range?

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

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

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* 15. If you are an interracial couple, indicate the combination in the comment box. For example: Woman African American, man Hispanic.

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* 16. What aliases or "fake names" would you prefer to use for publication purposes?

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