Please fill out the form below. In order for us to receive an accurate response
from your dating partner, please make sure the information you provide us
is complete and true to the best of your knowledge.

The service fee is $29.99.
You are only charged if we receive a response from your dating partner.
An invoice will be sent to you from PayPal upon your dating partners response.

ALL FIELDS ARE REQUIRED Please give us a brief description of the dating experience you are having:
Please provide your contact information:
	Name:
	Phone #	(xxx-xxx-xxxx)
	Email:
Please tell us how to get in touch with your dating partner:
	Name:
	Phone #:	(xxx-xxx-xxxx)
	Email:
Information you provide us is strictly confidential. We will NOT discuss the results of our intervention with any other party.