Couples' Dissatisfaction Scale

Couples' Dissatisfaction Scale
Please complete individually, by each individual separately. Do not discuss or share. Please complete and submit.

On a scale of 1 - 10, rate how dissatisfied you are

1 = Very Satisfied 10 = Very Dissatisfied
Name*

First NameLast Name
Date of Completion*

MonthDayYear
Date
Degree of Closeness
1 - 10
Expression of Affection and Caring
1 - 10
Satisfaction with Sexual Intimacy
1 - 10
Expressing of Anger and/or Blame
1 - 10
Handling Family Finances
1 - 10
Handling Parenting Issues
1 - 10
Common Interests and Social Life
1 - 10
Other Communication Problems
1 - 10
Infidelity, Emotional Attachment to Another
1 - 10
Other Things From Past Impacting Relationship
1 - 10
Relationships With Extended Family, inlaws, etc.
1 - 10
Please add any details about the main areas of concern
How are you hoping counselling at this time can help? (Be specific to your pain points above)*
Should be Empty: