Pre-Dating Questionnaire:

1) Are you now or have you ever been on heroin, oxycodone or any other mind-altering, massively addictive “recreational” drug?

2) How many therapists are you currently seeing?
(More than one is a red flag.)

3) How many therapists have you seen in the last three months? (More than one has passed red flag and gone flying into Seek Shelter Immediately siren territory)

4) Do you have a love child from a former partner? That is still in your life? With her current girlfriend and their love child?

5) Are you actually a lesbian or are you just working on a new life experience?

6) Do you have daddy and/or mommy issues? If so, on a scale of 1 to 10, how would you rate them?
(1 being “Not really” and 10 being “DANGER WILL ROBINSON DANGER!!!!”)

7. Did you major/minor in Psychology? If so, why? (Refer to question #6 if necessary.)

8. Regarding question #6 and #7 if answered in the positive – What exactly makes you get off about screwing with another persons head? The flip-trip-and-reversing of the other persons words? Watching the other person struggle? Or is it just the Power Trip that you hadn’t experienced until now?

9. Can you allow yourself to be vulnerable?

10. If “Yes” to question #9 – Will you allow yourself to remain vulnerable if the person you opened up to screws up once?
10a. Will you tell the person how you feel? Y / N
10b. If “No” – Why?

11. Do you give second chances?

12. If “No” to question #11 – Why not? Surely you’ve been given at least one second chance in your lifetime, no?

13. What are you afraid of?

___________________ Print Name
___________________ Sign Name
____________ Date



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