We suggest that you use this questionnaire to gain greater clarity before answering the basic questionnaire.

A. have you had previous relationships: If yes:

1. Are there specific types of partners that you attract or are attracted to?

2. Is there a certain type of partner towards which you feel aversion?

3. Were you happy in these relationships?

4. In general did you leave the relationship or did the other?

5. What do you believe were the factors that played a role in these relationships not working out?

6. Did you play a role in their not working out? If so what was your contribution?

7. Do you notice any patterns in your relationship situations and interactions? If so which?

8. What lessons might you be able to learn from these previous relationships?

9. Were there also very pleasant and positive moments in those relationships? If so, which?

B. Your parental prototypes:

1. How would you describe the your parental prototypes: a. Your Mother b. Your Father c. The relationship between them ' the ways in which they interacted and communicated ' or did not. d. Your own relationship with you mother e. Your own relationship with your father.

2. Were there behavioral similarities between any of your previous partners and one or more of your parents. If yes, A. Which were they? B. What might you need to learn by having 'chosen ' as a soul' to have a number of close persons with similar behaviors? C. What do you want to learn or do in relationship to that?

C. Is there a difference between what society and / or your parents want for you and what you want from a relationship? What do you want to do about that?

D. What is important for you to have in your relationship. (Have in mind that you might be able to have all of these, and maybe not. You might have to choose or sacrifice.) __1. To have a relationship at any cost. To have a partner, children, family? __2. To be in love with someone? __3. To be loved by someone? __4. To be able to share feelings and thoughts with someone? __5. To have a lively and interesting interaction with someone? __6. To be socially accepted because you are married? ___7. To have a relationship so as to be able to have children? ___8. To have a relationship in order to feel worthy to others. ___9. To have a relationship in order to feel safe and secure? ___10.To have a relationship so that there will be someone at home with me ' especially in the evenings. Other needs that you hope to have satisfied through a relationship. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

E. Have you noticed that you might have certain doubts, concerns or fears about creating a committed personal relationship. If so why? Consider the following possibilities.

1. We might fear intimacy because we fear: a. Being abandoned b. Being suppressed c. Being hurt d. Rejection e. That we will not be able to be ourselves f. If they know us deeper, they will not will not want to be with us. 2. We might feel vulnerable and afraid of being hurt if we are open and loving and prefer to keep an emotional distance. 3. We do not want to give the other the idea that he or she can do whatever he or she likes with us. 4. We would like them first to ask for forgiveness or at least realize their mistakes. 5. We fear we will lose control over them by letting them be too relaxed with us. 6. We want to place the blame for our dissatisfaction with ourselves or our lives on someone else who is "responsible". 7. We falsely believe that love requires that we must let this person do whatever he or she wants ' regardless of ethics or justice ' and that this would be totally unacceptable. 8. We have identified with the role of the victim and need to feel hurt and abused. 9. We are in the role of the interrogator and need to find others' faults. 10. We are afraid of expressing love, because we fear that there will not be an adequate response from others and we will feel rejected. 11. We cannot believe that others could possibly love us. 12. We have been seriously hurt by this person and cannot overcome this bitterness.

If you have been affected by these or other obstacles what can you do to get free?

F. Do you feel unhappy alone? For a few days? For a long time? If so, what obstructs you from being happy even when you are alone?

1. Are you afraid when alone? 2. Do you feel less worthy when alone? 3. Are you bored when alone? 4. Do you not know what to do with your time? 5. Do you feel that there is no meaning to life, when you are alone? 5. Do you feel badly because the others are in relationships and you are not? 6. What emotions do you have when you think: a. That you do not have a relationship at this moment? b. That you have not had a relationship for some time? c. That your previous relationships have not worked out? d. That some others have relationships and you do not?

7. What do you want or need to do in order to feel better alone until you meet the right person?

8. What do you believe will change in your life if you have a love partner? What will you have that you do not have now?

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