Couples Questionnaire

Instructions:

Please be thorough in your answers. If you need to stop midway through this questionnaire and finish it later, click on the link at the very bottom that says "Save and Continue Later" (next to the Submit button).

You must answer every question. If a question does not apply to you, just answer NONE or N/A, or provide a minimal response of some kind, so that the form will allow you submit your responses.

When you have completed all the of questions in the questionnaire, click the Submit button at the very bottom.

Briefly describe your hopes for our work together.*

What strengths do you have as a couple?*

How much does drugs or alcohol use impact or contribute to the situation? Please explain.*

When do you feel closest or most connected to your partner?*

How often do your arguments result in physical fighting such as hitting, grabbing, kicking, throwing things, blocking other person, etc. or verbal intimidation?*

How satisfied are you with the sexual intimacy in your relationship?*

How are you doing as a couple with decision-making, sharing responsibilities?*

What fears or worries do you have at this time about the relationship?*

What did your own family role model for you about relationships?*

How would you rate the level of trust you have with your partner?*

How hopeful are you that your relationship will thrive and grow?*

How much do you feel that your partner cares about you?*

Who do you feel or believe is most responsible for the problems in your relationship (yourself, your partner, both of you, some other factor/person)?*

The circles below represent different degrees of happiness in your relationship. The middle point, “happy,” represents the degree of happiness of most relationships. Please fill in the circle that best describes the degree of happiness, all things considered, of your relationship.*

Perfect (7/7)
Extremely Happy (6/7)
Very Happy (5/7)
Happy (4/7)
A Little Unhappy (3/7)
Fairly Unhappy (2/7)
Extremely Unhappy (1/7)

Which of the following statements best describes how you feel about the future of your relationship?*

I want desperately for my relationship to succeed, and would go to almost any length to see that it does. (6/6)
I want very much for my relationship to succeed, and will do all I can to see that it does. (5/6)
I want very much for my relationship to succeed, and will do my fair share to see that it does. (4/6)
It would be nice if my relationship succeeded, but I can’t do much more than I am doing now to help it succeed. (3/6)
It would be nice if it succeeded, but I refuse to do any more than I am doing now to keep the relationship going. (2/6)
My relationship can never succeed, and there is no more that I can do to keep the relationship going. (1/6)

If you are having suicidal thoughts, or have any thoughts or intent to harm yourself, please explain:*

Name*

First Last

Couples Questionnaire

Instructions:

Title