Simply replace the unfilled areas such as "" and "[date]" with your information.
Dear [name of love interest]
It seems that you have been distant lately, and I feel as if I have done something to make you angry. I don't know what I have done to push you away, but I am sorry if I have done anything to hurt you or make you angry.
I want to fix it, but I need you to be able to tell me what has driven you away so suddenly. Please be honest with me. I would love for our relationship to grow, but we both know that it takes work and honesty.
If you are ready to talk about it, please let me know. I am ready to listen.