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COUPLES QUESTIONNAIRE
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Please Contact: |
Check if you would like to be contacted) |
First Name: |
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Last Name: |
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Email Address: |
(Required) |
City, State: |
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Phone Number: |
| 1. | What is the problem that
led you to decide to come to therapy? |
| 2. | How long have you and your partner been
together? In what form? (i.e., dating, living together, married) |
| 3. | What initially attracted you to your partner? |
| 4. | How was the decision to live together or marry
made? |
| 5. | What was the very beginning of your relationship
like? How long did this phase last? |
| 6. | What was your first disillusionment? What
happened and how did you resolve it? Did this lead to any changes in your relationship? |
| 7. | When did you first become aware of significant
differences between the two of you? In what important ways are the two of you similar?
Different? How do you resolve these differences ? |
| 8. | What do you do when you are angry? What does
your partner do when angry? |
| 9. | Do you spend time in activities away from your
partner? If so, how often? Doing what? |
| 10. | Do you spend time alone or with people who are
not mutual friends? Does this create conflict in your relationship? |
| 11. | Do you enjoy your free time? Does planning how
to spend it create anxiety for you? |
| 12. | How comfortable are you doing activities away
from your partner? How comfortable are you with your partner spending time away from you? |
| 13. | On a scale of 1 to 10, how open are you in
expressing your innermost thoughts and feelings to your partner? (1 is totally closed and
10 is totally open) |
| 14. | When you feel like you need support or
encouragement from your partner, do you get it? How? |
| 15. | When your partner needs support or
encouragement, do you feel that you give it? How? |
| 16. | Do you support your partner's development as an
individual? How (give example)? Do you support his/her growth as an individual even when you don't agree? How (give example)? |
| 17. | Describe your sexual relationship. What do you
find most satisfying about it? What do you find least satisfying about it? |
| 18. | When do you feel most gratified in your
relationship? |
| 19. | When do you feel most frustrated in your
relationship? |
| 20. | Do the two of you have joint commitments to
goals, projects, work, or social causes? Does this add or detract from the bond between
you? |
| 21. | If your relationship was a movie, drama or book,
what would it be titled? How would it end? |
End of Questionnaire.
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