What is you current marital status?
Select from list
Single
Annulled & Divorced
Widowed
Select from list
Single
Annulled & Divorced
Widowed
Date of Birth
Number of years in current relationship
Select from list
0-2 Years
3-5 Years
6-10 Years
11+ Years
Select from list
0-2 Years
3-5 Years
6-10 Years
11+ Years
Are you currently cohabiting?
No Yes
No Yes
Children from current relationship?
No Yes
No Yes
Children from previous relationship?
No Yes
No Yes
What is your occupation?
Select from list
Professional
Managerial
Skilled / Clerical
Semi Skilled / Unskilled
Unemployed
Home duties / Full-time parent
Student
Self-employed
Retired
Other
Select from list
Professional
Managerial
Skilled / Clerical
Semi Skilled / Unskilled
Unemployed
Home duties / Full-time parent
Student
Self-employed
Retired
Other
What is your religion?
Select from list
Roman Catholic
Other Christian
Other Faith
None
Select from list
Roman Catholic
Other Christian
Other Faith
None
What is your nationality?
Level of education attained?
Select from list
No Formal Education
Primary Education
Secondary Education
Third Level Education
Select from list
No Formal Education
Primary Education
Secondary Education
Third Level Education
How did you hear about this ACCORD Service?
Select from list
Family
Friends
Work Colleagues
Priest / Church
From another ACCORD Service
Poster
Always knew about ACCORD
TV
Radio
Internet
Lawyer
Court
Golden Pages
Magazine
Family Doctor / Health Care
Don't Recall
Other
Select from list
Family
Friends
Work Colleagues
Priest / Church
From another ACCORD Service
Poster
Always knew about ACCORD
TV
Radio
Internet
Lawyer
Court
Golden Pages
Magazine
Family Doctor / Health Care
Don't Recall
Other