Sunday, 27 May 2012

Would you like to contribute to my book?

Dear Readers,
I need your help for a self help book I'm writing for people going through broken relationships and aching hearts. If you have gone through a rough relationship that left you shattered, please go through this questionnaire and email me in detail.

I………………………………………………………………………….., hereby give permission to Nikeeta Bhargava to use all or part of my interview , for her currently titled book “ Broken Hearts Anonymous”. I have understood hereby, that , incidents from my life are going to be used for anecdotal purposes’.
I am ok with my real name being used
I wish to be quoted under anonymity
This permission is for all editions of the book that may be published; they may be used for promotional purposes or as excerpts from the book in any medium by the author.
The author has agreed to inform me, if all or any part of my interview will be utilized in her book at the time of publication.
I am aware this interview is being recorded.
This interview is completely out of my choice, voluntary and pro-bono.


1.       Name
2.       Current Age
3.       Maritial Status
4.       Relationship Status
5.       Please tell in detail the story of your relationship
6.       Age at time of relationship
7.       How long did the relationship last
8.       What makes this relationship so significant in your life/difficult to replace
9.       Reason why the relationship did not work out
10.   Who broke up the relationship
11.   How did you deal with the initial stage of being single again
12.   Did you hold onto the hope that the person will come back to you?
13.   How long did you hold onto that hope?
14.   Did you go through a period of grieving/depression/loneliness
15.   How did you deal with this phase
16.   How long did it last
17.   Did you have external support
18.   Was your family in favour of your relationship
19.   Were they aware of your break up
20.   Did you go through an angry phase
21.   How did you deal with your anger?
22.   Did you get into any re-bound relationships?
23.   Did you develop any fear or aversion to intimate relationship or commitment?
24.   Did the break up change your perception about yourself
25.   Did you lose your confidence/ self esteem/ security etc
26.   What was the best part of that relationship
27.   What was the  worst part of your relationship
28.   In hind sight what do you feel about the relationship
29.   Do you feel , you are completely over that person?
30.   How do you/would you react if you came face to face with that individual now?
31.   Did you blame God/destiny/someone else for not being together any more?

32.   What fairy tale/story/film do you identify most similar to your story

Please mail me at

I appreciate your inputs and help

God Bless

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