Please take the time to complete this questionnaire thoughtfully. Your answers will help us to address your needs. The generic word “partner” will be used in place of wife, husband, boyfriend, fiancée, etc. Thank you.







    Your partner's age:

    Are you married?
    YesNo
    Do you have children?
    YesNo
    How long have you been married (years)?

    How long have you been together (years)?

    How long have you lived together (years)?





    How did you meet?




    At the beginning of your relationship, who tended to be the pursuer or initiator?




    If those roles changed over time, who is the pursuer now?




    What made you fall in love with your partner (use words like chemistry, sense of humor, intelligence, good communication, etc.)?




    What do you like the most about your partner today?




    Please describe your major concern(s) about your relationship:




    Please describe any history of physical aggression or violence in your relationship:




    Please describe any concerns you have about alcohol, drugs, or other addictions (yourself and your partner):




    Please describe any history of infidelity in your relationship (affairs or flirtations, emotional or physical):



    Level of trust I have in my partner:  1-low 5-high
    12345

    Level of emotional support I feel in this relationship:  1-low 5-high
    12345

    Level of affection (non-sexual):  1-low 5-high
    12345

    Amount of fighting or distressing arguments:  1-low 5-high
    12345

    Amount of emotional and physical distance:  1-low 5-high
    12345

    I usually feel lonely or shut out in this relationship:

    My partner is mostly there for me:

    I feel I can lean on my partner for support:

    I generally feel a strong sense of connection with my partner:





    When there is distress in a relationship, there are normal patterns of interaction that become frustrating and hurtful - such as complaining, blaming, defensiveness, fighting, and distance.










    I express my needs:
















    We are strongly influenced by the relationships we experienced growing up. Please describe your childhood experience with your parents and other significant people in your life.







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