PARTICIPATION FORM:

I, WOULD LIKE TO BE CHOSEN TO PARTICIPATE IN THE RESEARCH STUDY.

ADRS:    (STREET CITY STATE ZIP)

TELEPHONE NUMBERS:

HOME:  

CELL:    

E MAIL ADDRESS:

GENDER:

AGE: (aprx)             

PROFESSION:

Please select a relationship with someone in your life that you interact with on a daily basis (or at least 3-4 times a week) that is not as loving as you would like it to be.

My Definition of Love is:

 I UNDERSTAND THAT ANY AND ALL STATEMENTS I MAKE AND INFORMATION I CONTRIBUTE WILL BE HELD IN THE STRICTEST OF CONFIDENCE. I ALSO UNDERSTAND THAT THIS INFORMATION WILL BECOME THE SOLE PROPERTY OF MR. DEUTSCH, AND CAN BE USED IN RESEARCH PAPERS, PRINTED MATERIALS, BOOKS, ETC., AT HIS DISCRETION, AND WILL, IN ALL MANNER, REMAIN ANONYMOUS.

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