You don't need to fill in your name and email address if you prefer. Your answer can be totally anonymous.
But please give as much detail as you can (and feel comfortable with) about your emotional challenges in romantic relationships. It will help me to identify the most important topics and themes to include in my new email series so it can be as relevant and helpful to you as possible.
All information you provide is confidential, will be stored securely in anonymised form (i.e. it will be impossible to identify you from the information you gave) and will never be shared with anyone.