Couples Questionnaire | Relationship Center of South Florida

Name(Required)

Email(Required)

Date of Birth(Required)

Name of partner

Age of partner

Married

Yes

No

How long have you been married (if applicable)

How long have you been together

How long have you lived together

Do you have children

Yes

No

Names/Gender/Age

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

What is your goal(s) for couples therapy? What do you hope for?

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

Parents

Siblings

What did you most need that you didn’t get growing up?

Who could you rely on growing up?

How were you emotionally supported & by whom?

Other comments about your childhood relationships

QuestionnaireFor couples

Center Information

Therapy & Counseling

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