First Name:

Middle Name:

Last Name:

Email:

Hair Color:
Blonde Brown Red Black Other

If you've selected 'other' - please clarify: 

Eye Color:
Blue Brown Green Other

If you've selected 'other' - please clarify: 

Your body type:
Petite Thin Athletic Average A few extra pounds Curvy Heavy

Enjoyments/Hobbies:

Vices: (alcohol, smoking, etc.)

Are you the life of the party or a wallflower?
Life of the Party Wallflower

Are you a sensitive person?
Yes No

Are you good at following rules and guidelines?
Yes No

Do you like our current president?
Yes No Other

If you selected 'other', please clarify:

5 Favorite books, movies, or TV shows:

Favorite type(s) of music:

Favorite Foods: (Omnivore, Vegetarian, etc.)

Do you have pets?
Yes No

If yes, what kind?

Tell us about you. What are some of your positive and negative traits?

Who are your three celebrity crushes?

When was your last relationship?

If separated or divorced, how is your relationship with your ex?

Describe your last 'ex':

What are your five "must-haves" in a relationship?

What are your five "deal breakers" in a relationship?

Tell us all about your (Potential or Existing) mate physically, mentally, and emotionally:

Dating career preferences: (homemaker, student, executive, entrepreneur, etc.)

Dating education preference:  (you can check more than one box)
High-School Associates Bachelors Masters PhD Doctorate No-Preference

Dating personality preferences: (extrovert, introvert, etc.)

Dating income level requirements:  (you can select more than one box)
Under $25,000 $25,000-$50,000 $50,000-$100,000 $100,000-$150,000 $150,000-$250,000 $250,000-$1,000,000 Over $1,000,000 Over $5,000,000 No Preference

Dating height range:
Minimum Height: 4' 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11"    Maximum Height: 4' 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11"

Dating location range:
Within:  50 Miles 100 Miles 200 Miles 500 Miles My State Anywhere

Will you date someone that lives more than two hours from you?
Yes No

Are you willing to relocate for Love?
Yes No

Please list all the dating sites you have used:

What Services are you most interested in? (you can check more than one box)
Love Introductions/Matchmaking Date Coaching Relationship Coaching Online Dating Profile Management Ex Services Joining our Dating Lovebase

Why do you want to work with us?

Your Facebook Link:

Other Social Network Links:

Anything else we should know about you, your ex, your love or your mate? Hold nothing back.

Clear