PGSC- DIVORCE THERAPY QUESTIONNAIRE

PG SEBASTIAN COACHING

A Relationship You Can Be Proud Of
Divorce Therapy Questionnaire
This Questionnaire is designed to provide information that will assist your counselor in understanding your unique needs. In completing it, kindly be guided by total openness and honesty, as this will influence the total outcome of your interaction with your counselor. Be assured that any information provided on this sheet and any other place during and in the course of your interaction with your counselor, would be treated with the utmost confidentiality.

Are both of your parents Alive?
IF you selected YES for the above question, Kindly answer the following question. Have they ever been separated by work, divorce or threat of divorce?
If you selected any of the above, kindly explain briefly.
Are they still married?
If YES, how long have they been married?
If NO, how long have they been separated?
How long did they live as a married couple before they separated?
Which of your parents did you live with after the separation?
If one of your parents is not alive, kindly provide the following information
Which of your parent is alive
Have they remarried?
If both of your parents are not alive, who did you live with until you married/left home?
At what age did you lose the last remaining parent?
If you have any other family experience other than the ones described above, [e.g. growing up with foster parents etc] briefly explain
Briefly describe the home atmosphere you grew up in
Would you say the home atmosphere you described has had any negative impact on you?
If YES, kindly explain briefly

Do you have any children?
If yes, list their Ages And Gender
Are all the above listed children your biological children?
If No, kindly indicate those that are not yours and those that are your and how you came to have them in your household.
Are all your children your from your current spouse?
If No, kindly indicate which ones are from your current spouse and which ones are not and how you came to be with them.
What is the relationship between your spouse and the children

Tick as appropriate the following options after each question. [Me] [Spouse] [Both] [None] [Other]

Rows	Me	Spouse	Both	None	Other
Who do the children spend time with for leisure?
Who do the children confide in with their challenges and secrets?
Who do the children go to for their financial and other material needs?
Who do the children go to in moments of happiness?
Who do the children go to in moments of sadness?
Who do you think the children trust the most?
Who do you think the children respect the most?
Who do you think the children fear the most?
Who would the children easily obey without question
Who do you think the children love the most?

Do you have any other children who depend on you but are not your own?
If yes, list their sexes, ages and explain how they came to depend on you
How is your spouse’s relationship with the other children in your care like, if any
Does your spouse play their Role generally in the entire running of the home? (Tick as appropriate)

All the timeMost of the timeSometimesFew of the timesNot at all
Kindly explain if you have any need to explain your choice of answer to the above question

Does anyone of you have problems with Decision making?
If Yes, briefly explain
Does any of you sense a subtle or open power struggle?
If Yes, briefly explain
Has any of you hinted the other about this subtle or open power struggle?
If Yes, briefly explain
Who is the main driving force behind getting things done and getting decisions taken?
Does any of you financially depend on the other?
If Yes, briefly explain why, and name the financier.
Does the financier see it as a burden?
If Yes, how has it been communicated?
How does the financed party feel about this? (Tick as Appropriate)

ComfortableUncomfortableFeels ControlledFeels Weak And DisadvantagedAppreciative
Have you lived in the same house all this while?
If Yes, who owns the house?
Who pays the Rent if it is a rented place?

Who primary is asking for the divorce?
Kindly summarize the reasons they have given for wanting the divorce (the details will be asked in session)
What DO YOU think or suspect are the real causes or reasons behind the desire to want out (If it is you wanting the divorce and the reasons are the same as above, kindly write, 'same as above' )
Do you suspect any Push Factor(s) within the marriage? (Something the one wanting out can’t handle in the marriage?)
If Yes, kindly explain briefly
Do you suspect any Pull Factor(s) outside of the relationship? (Something that is enticing and drawing out the one wanting out of the marriage)
If Yes, kindly explain briefly

Briefly state why you are coming for this counselling
Kindly mention at least three (3) things you hope to achieve from these sessions
Please list the names of counsellors, psychologists, psychiatrists or physicians you have worked with in the past. Kindly add the year and length of session you had with each one.
Why did you change the previous counsellors?
I hereby declare and agree that the information provided above to my best of knowledge is accurate and true and shall form the basis for this and any subsequent counselling sessions with PG Sebastian Coaching unless otherwise advised. I agree that the information provided herein shall be deemed confidential and shall not be used or divulged to any other person not affiliated to PG Sebastian Coaching for any purpose without my prior notice.
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