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By completing this Survey you will keep Face Reality up-to-date on the needs of
people in situations like yours.

1. Are you male or female?:
2. Your geographic location: City/Town: State:
3. Your age:
4. Tell us a little about yourself: Are you?
5. Where are you at this time?:
6. Are you currently?:
7. Your role in the love triangle is the:
8. My affair/betrayal started because of:
9. Do you see a pattern in your marriage/relationship as the?:
10. Are you?:
11. This is my:
12. Which do you think is a high priority of an affair?
13. Were extramarital affairs part of your parents' history?
14. Do you believe affairs have consequences?:
15. Which consequence have you experienced?:
16. What would help your recovery?:
Contact E-mail address:
        Accept email from Elissa? Yes No

Name & mailing address


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