NOTE: If you are dating more than one person, please complete the survey thinking about the romantic partner that means the most to you.
Are you...
Married
Engaged
Dating seriously - dating a steady partner and no one else
Dating casually - dating more than one person
Single
How long (in months) have you known your current partner?
How long (in months) have you been together as a couple with your current partner?
Please indicate the degree of happiness, all things considered, of your current relationship.
Extremely
Unhappy
Fairly
Unhappy
A little
Unhappy
Happy
Very
Happy
Extremely
Happy
Perfect
Are you currently in couples counseling?
Yes
No
Have you ever been in couples counseling?
Yes
No
How old are you?
How old is your partner?
What is your gender?
What is your partners' gender?
Caucasian
African
American
Latino
Hispanic
Asian
Pacific
Islander
Native
American
Middle
Eastern
Other
What is your racial and
ethnic background?
What is your partner's racial/
ethnic background?
Less than
10th grade
10th
grade
11th
grade
HS
diploma
Some
college/
trade school
AA degree/
trade school
certif.
BA/BS
degree
MA/MS
degree
Law
degree
PhD/
PsyD
DDS
MD
Your highest degree:
Your partners?
No
Part-time
Full-time
(40 hrs/week)
More than
60 hrs/week
Are you currently in school?
Is your partner in school?
Are you currently working?
Is your partner working?
What is your MONTHLY INCOME (before taxes)?
What is your partner's MONTHLY INCOME (if known)?
How did you find out about this survey?
Please try to be specific with your answer
For example:
email from a friend
Google search
www.theNest.com
www.CanadianBride.com
NOTE: If you were given a postcard with a code word, please enter the codeword here.
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