Relationship Management Assessment
Please fill the Form below. Answer all the Questions. Dont think too much. Fill it With The Answer that comes first to your mind. Your response will be kept confidential. It will be used only for treatment and research purpose. Copyright © 2021 psyclinic
Name/ nick name
Email
example@example.com
Date of filling the form
-
Month
-
Day
Year
Date
Other members of your family/others who lives with you
The members you felt as very significant in your life. (a) in the past (b) at present. Please specify the reasons to choose them.
The family/other member/s towards whom you feel great dislike/hatred.
Specify the reason if any.
How long you had been experiencing the strain in relationship with that person?
What do you think as the major reason for this strained relationship?
What is the major complaint that the other person raise against you?
List a few positive aspects of the person whom you dislike.
Did you try to do anything to improve the relationship earlier? If yes, please specify it.
What do you think as the most important value that one should that one should keep up in a relationship?
What do you think are the benefits of making an improvement in the relationship. (consider all aspects like other family members, social, vocational, personal, financial improvement etc.)
What do you think are the consequences if you did not make an improvement in the relationship?
Do you use any substance like alcohol, cannabis, opiates, nicotine etc. If yes specify details like type of substance, quantity of intake, how often you use it etc.
How often you feel the following in your relationship
Never
Rarely
Sometimes
Most times
Always
a detachment towards all or certain members of your family
no one in your family understands you
relationship will not improve on passage of time
adjustment problems with your colleagues at work place
you are trapped into this relationship/taken a wrong choice ( in case of spouse)
one cant trust anyone
the strain you are taking to keep up the relationship exhausts you
the other person can never understand you
you are mistreated by the other person
you are verbally abused by the other person
you are physically abused by the other person
How intense you dislike the other person
1
2
3
4
5
How intense does the strained relationship affects your daily life activities.
1
2
3
4
5
How intense is your motivation to change for a better relationship
1
2
3
4
5
How intensely you are ready to work towards improving the relationship
1
2
3
4
5
Signature
Clear
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