Couples Love Within Time

* What is your gender?

* What is your age?

* What racial or ethnic group best describes you?

* How would you categorize your current primary relationship?

* Based on your relationship efforts, which action would improve your current relationship? (choose one)

* Based on your significant other's relationship efforts, which would improve your current relationship? (choose one)

* How long of a time period do you believe it takes to fall in love?

For each of the following statements, use the criteria listed that best describes your current primary relationship.

	Strongly Agree	Agree	Unsure	Disagree	Strongly Disagree
* I love my significant other

* I want to stay in a relationship with my current partner

* I have adequate opportunity to personally grow and develop in my relationship

* I am dependent upon my significant other for my happiness

* I am afraid to be on my own

* We have good times together often

* We make a good couple

* Our communication is effective

* I am happy with the level of intimacy in my relationship

* I am interested in having an affair outside of my relationship

* Our sexual relationship is adequate

* I am thinking about leaving the relationship

* Choose the top 3 factors that you believe are critical to a happy loving relationship? (choose 3)

* What method is mostly used to communication in your primary relationship?