Couples Forms

Aron Hirschfeld, LMSW

Couples Questionnaire
Name *

First Name Last Name
Email
example@example.com
The A.R.E. Questionnaire

Answer the questions using a scale 0-10. 0= Strongly Disagree, 10= Strongly Agree
Accessibility: From your viewpoint, how accessible is your partner to you?
I can get my partner’s attention easily.
My partner is easy to connect with emotionally.
My partner shows me that I come first with him or her.
I am not feeling lonely or shut out in this relationship.
I can share my deepest feelings with my partner. He or she will listen.
Total for Accessibility
Responsiveness: From your viewpoint, how responsive is your partner to you?
If I need connection and comfort, he or she will be there for me.
My partner responds to signals that I need him or her to come close.
I find I can lean on my partner when I am anxious or unsure.
Even when we fight or disagree, I know I am important to my partner and we will find a way to come together.
If I need assurance about how important I am to my partner, I can get it.
Total for Responsiveness
Engagement: From your viewpoint, how positively, emotionally engaged are you with each other?
I feel very comfortable being close to and trusting my partner.
I can confide in my partner about almost anything.
I feel confident, even when we are apart, that we are connected to each other.
I know that my partner cares about my joys, hurts, and fears.
I feel safe enough to take emotional risks with my partner.
Total for Engagement

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Aron Hirschfeld, LMSW