I am comfortable telling people I am separated from my love partner *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel rejected by many of the friends I had when I was in the love relationship *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel comfortable seeing and talking to my Ex *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I am relating and interacting in many new ways with people since my separation *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Joining a singles group would make me feel I was a loser like them *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Because my love relationship failed, I must be a failure *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I hope my Ex is feeling as much or more emotional pain than I am *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I have close friends who know and understand me *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel capable of building a deep and meaningful love relationship *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Because my love relationship ended, I feel there must be something wrong with me *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I either have no appetite or eat continuously which is unusual for me *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I don't want to accept the fact that our love relationship is ending *

Almost Always

Usually

Sometimes

Seldom

Almost Never

It is important that my family, friends, and associates be on my side rather than on my Ex's side *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel uncomfortable even thinking about dating *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I have noticed my body weight is changing a great deal *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I believe if we try, my love partner and I can save our love relationship *

Almost Always

Usually

Sometimes

Seldom

Almost Never

My abdomen feels empty and hollow *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I have feelings of romantic love for my Ex *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I would like to get even with my Ex for hurting me *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I have really made a mess of my life *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I believe it is best for all concerned to have our love relationship end *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I become upset when I think about my love partner having a love relationship with someone else *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I am afraid of becoming sexually involved with another person *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I would like to continue having a sexual relationship with my Ex *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Life is somehow passing me by *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel comfortable going by myself to a public place such as a movie *

Almost Always

Usually

Sometimes

Seldom

Almost Never

It is good to feel alive again after having felt numb and emotionally dead *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel emotionally committed to my Ex *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I am afraid of becoming emotionally close to another love partner *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Even on the days when I am feeling good, I may suddenly become sad and start crying *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I can't believe our love relationship is ending *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I become upset when I think about my love partner dating someone *

Almost Always

Usually

Sometimes

Seldom

Almost Never

Morally and spiritually, I believe it is wrong for our love relationship to end *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I wake up in the morning feeling there is no good reason to get out of bed *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I find myself daydreaming about all the good times I had with my love partner *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel comfortable going to social events even though I am single *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel guilty about my love relationship ending *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel uncomfortable even thinking about having a sexual relationship *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel emotionally weak and helpless *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I think about ending my life with suicide *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel comfortable having my friends know our love relationship is ending *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I am angry about the things my Ex has been doing *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel like I am going crazy *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I am unable to perform sexually *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel like a single person rather than a married person *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I feel my friends look at me as unstable now that I'm separated *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I daydream about being with and talking to my Ex *

Almost Always

Usually

Sometimes

Seldom

Almost Never

I need to improve my feelings of self-worth about being a wo/man *

Almost Always

Usually

Sometimes

Seldom

Almost Never

What is your gender?

Female

Male

Prefer not to say

Do you have kids?

None

0-5 years old

6-10 years old

11-18 years old

19 or older

What do you do during normal work hours?

Stay at home parent

Physical/Active type of job

Managerial job

Desk Job

Not currently working/Other

Where are you in the divorce process?

Considering divorce

In the divorce process

Divorced

Did you initiate the divorce?

Yes

It was mutual

How long were you or have you been married?

0 to 5 years

6 to 10 years

11 to 15 years

16 to 20 years

21 years or more

How long ago did you get divorce or when do you expect to be divorced?

0 to 1 year ago

1 -2 years ago

2-5 years ago

6 or more years ago

In the next month

Sometime this year

Not sure

Please tell us a little bit about what happened (optional)

Did you/do you have many friends or family to talk to and support you during your divorce and soon after? (optional but very helpful)

Yes

Is there anything else you would like to share with us that might be helpful?

First Name

Last Name

Phone

Email (in order to receive your results) *

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