Post Relationship Self-Evaluation Form

OMB CONTROL NO.7-1405 EXPIRATION DATE 09/20/2025
Post Relationship Self-Evaluation Form
**READ INSTRUCTIONS CAREFULLY BEFORE FILLING OUT FORM
INSTRUCTIONS
This is a form to determine your status following the conclusion of interpersonal relations between one (1) or more persons as defined under Section 0097(B-8 You may also be eligible for this form if you meet the following requirements: 1) You are evaluating a relationship formally described as friendship but are considering alternative possibilities; 2) The relationship has not concluded but it may within ten (10) days to three (3) months; and/or 3) You are using this as personal documentation to reflect on yourself and evaluate your ongoing relationship to others, maintenance of boundaries, or communication strategies.

You are NOT required to fill out this form regarding relations between intrapersonal or non-human entities.

This document is NOT legally binding and is liable to change.
SECTION 1. DEFINING TERMS AND/OR FRAMEWORK
1. How would you describe your relationship?

SituationshipOpenPolyamorousOne Night StandCommitted MonogamousNon-Committed MonogamousFriends with BenefitsUndefinedOther
2. How long did the relationship last?

One Day or LessA Weekend1-3 WeeksA Month2-5 Months6 Months to a Year1-2 Years3+ Years
SECTION 2. INTERPERSONAL COMMUNICATION

3. How well did you communicate the following?

Rows	Not Communicated	Somewhat Implied	Implied	Somewhat Clear/Direct	Clear/Direct
Initial Intentions
Boundaries
Wants & Need (PHYSICAL)
Wants & Needs (EMOTIONAL)
Short Term Goals
Long Term Goals
Romantic Ideals
Relevant Past
Relevant Health

3.a Was there a reason you specifically chose to not communicate one or more of these things? If so, what was the reason?

4. How well did you listen to and apply the following?

Rows	Not Communicated	Somewhat Implied	Implied	Somewhat Clear/Direct	Clear/Direct
Initial Intentions
Boundaries
Wants & Need (PHYSICAL)
Wants & Needs (EMOTIONAL)
Short Term Goals
Long Term Goals
Romantic Ideals
Relevant Past
Relevant Health

4.a Was there a reason you specifically chose to not listen or apply one or more of these things? If so, what was the reason?
5. Did you feel actively listened to?

YesNo
SECTION 3. ENJOYMENT AND SAFETY
6. How much did you enjoy yourself during this relationship?
While Alone:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
While With Partner:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
7. How often did you consider the safety of your partner?

All the timeMajority but not allSometimesRarelyNot at all
8. How often did you feel safe during this relationship?

All the timeMajority but not allSometimesRarelyNot at all
SECTION 4. THE ENDING
9. Who initiated the end?

YourselfThe other person(s)
9.a For what reason did the relationship end?
9.b How well was the ending communicated?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
9.c How well was the ending received?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
10. If given the opportunity to revisit how the relationship ended, would you?

YesNo
10.a If yes, how so ? If not, why not?
SECTION 5. PERSONAL REFLECTION
11. In what ways did you change as a result of this relationship?
12. Are there any aspects of yourself that were altered or minimized for this relationship that you'd like to return to?

YesNo
Explain
13. Are there any aspects of yourself that were altered or expressed for this relationship that you'd like to let go of?

YesNo
Explain
14. Will you approach your next relationship differently as a result of this one?

YesNo
14.a How so?
15. Are you likely to re-engage with this relationship or one similar in the future?

YesNoMaybe
From 1 to 10, rate yourself overall as a participant in this relationship:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Notes:
Should be Empty:

Post Relationship Self-Evaluation Form

**READ INSTRUCTIONS CAREFULLY BEFORE FILLING OUT FORM

INSTRUCTIONS

SECTION 1. DEFINING TERMS AND/OR FRAMEWORK

SECTION 2. INTERPERSONAL COMMUNICATION

SECTION 3. ENJOYMENT AND SAFETY

SECTION 4. THE ENDING

SECTION 5. PERSONAL REFLECTION