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BirdSong Education and Counseling -  Home  Contents

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COUPLE RATING SCALE

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First Name:

Last Name:

Email Address:

(Required)

City, State:

Phone Number:

Instructions:

Rating scale is from 1 to 10 with 1 being the lowest and 10 the highest. You will rate yourself in the first column. In column one, rate your CURRENT level of each trait. Column two is for rating your partner. In column two, using your PERSONAL PERCEPTION, rate his/her CURRENT level of each trait.

LIFE AREA

SELF
CURRENT
PARTNER
CURRENT
COMMUNICATION LIFE
1. Degree of listening skill

2. Degree of sensitivity and respect

3. Degree of honesty

4. Degree of openness

5. Degree of flexibility/compromise

HOME LIFE
6. Degree of satisfaction with household responsibilities

7. Degree of completing household responsibilities

8. Degree of role flexibility

9. Degree of good parenting skills

WORK LIFE
10. Degree of fulfillment in own career

11. Degree of comfort with partner's career

12. Degree of balance between work/home life

LOVE LIFE
13. Degree of acceptance of other

14. Degree of mutual understanding

15. Degree of trust in other

16. Degree of expressed (spoken) love

17. Degree of Implied (unspoken) love

18. Degree of forgiveness in relationship

SEXUAL LIFE
19. Degree of frequency

20. Degree of satisfaction

21. Degree of excitement in lovemaking

22. Degree of variety In lovemaking

SPIRITUAL LIFE
23. Degree of spiritual belief

24. Degree of

25. Degree of comfort with spiritual expression

PROBLEM SOLVING LIFE
26. Ability to talk about problems (get them in the open)

27. Ability to work through problems

28. Ability to "fight fair"

29. Ability to resolve family-of-origin problems
DREAM FOR THE FUTURE LIFE
30. Degree that your dream is also his/hers

31. Degree that your dream is mutually decided

End of Questionnaire.
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Last modified: February 02, 2010