Relationship Questionnaire

Prior to your first appointment, please answer all questions below. Do not spend too much time on any question.

Your Name:

First Last

Your Email:

Name of Partner:

First Last

Relationship status (check all that apply):

Married

Separated

Divorced

Dating

Cohabitating/living together

Living apart

Length of time in current relationship:

As you think about the primary reason that brings you here, how frequently does it occur?

No occurrence

Occurs rarely

Occurs sometimes

Occurs frequently

Occurs nearly always

As you think about the primary reason that brings you here, how would you rate your overall concern about it?

No concern

Little concern

Moderate concern

Serious concern

Very serious concern

What do you hope to accomplish through counseling?

What have you already done to deal with the difficulties?

What are your biggest strengths as a couple?

Please rate your current level of relationship happiness by selecting the number that corresponds with your current feelings about the relationship: (1 = Extremely unhappy, 10 = Extremely happy)

Please enter a number from 1 to 10.

Have you received prior couples counseling related to any of the above problems?

Yes

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:

If you have received prior couples counseling, when did this occur? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, where did it occur? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, who counseled you? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, what was the length of the treatment? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, what were the problems that were treated? (If you have not received prior couples counseling, please type N/A.)

Have either you or your partner been in individual counseling before?

Yes

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?

Yes

If you have received prior couples counseling, what was the outcome? (If you have not received prior couples counseling, please select N/A.)

Much worse

Somewhat worse

Stayed the same

Somewhat successful

Very successful

N/A

Have either of you threatened to separate or divorce as a result of the current relationship problems?

Yes

N/A

Have either you or your partner struck, physically restrained, used violence against, or injured the other person?

Yes

Do you perceive that either you or your partner has withdrawn from the relationship?

Yes

If married, have either you or your partner consulted with a lawyer about divorce? If not married, please answer N/A.

Yes

N/A

How frequently have you had sexual relations during the last month?

How satisfied are you with the frequency of your sexual relations? (1 = Extremely unsatisfied, 10 = Extremely satisfied)

Please enter a number from 1 to 10.

How enjoyable is your sexual relationship? (1 = Extremely unpleasant, 10 = Extremely pleasant)

Please enter a number from 1 to 10.

What is your current level of stress (overall)? (1 = No stress, 10 = High stress)

Please enter a number from 1 to 10.

What is your current level of stress (in the relationship?) (1 = No stress, 10 = High stress)

Please enter a number from 1 to 10.

List your top three concerns that you have in your relationship with your partner (1 being the most problematic):

Thank you for completing this. Please note that you will be asked to talk about your answers in appointments, but your partner will not be shown this form.