Please fill out this form completely to enable us to fine tune your matching. We appreciate your cooperation so that we can better serve you. Your responses will not be shared with your referral. Remember, feedback is vital for the overall success of your program and is required before receiving additional referrals.
Your Information... *required fields
* Full Name: (First and Last)
* E-mail address:
* Age:

 		* Contact Phone:
( ) -
About Your Referral... *required fields
* Introduction's Name:

Was a contact made? Yes No If not, why?
Was a date made? Yes No If not, why?
* Good or compatible qualities:
* Poor or incompatible qualities:
Will you be meeting again? Yes No Unsure
Please send my next referral?  Yes No
Please place my membership on HOLD
Yes No
Reason to Hold Membership: PleaseComments, Questions, Suggestions!:
Please give us additional comments about your Introduction...
Was your introduction fun?
 
Did you find your introduction interesting?
 
Was your introduction polite?
 
Was your introduction prompt?
 
Did you find your introduction attractive?
 
Was your introduction dressed appropriately?
 
Was this a "good" introduction overall?
 
© 2010 Heart to Heart Introductions