Beloved Life Care
Couples Survey
Who is filling out this form?
Your Age
Your Partners Age
Your Annual Income
Please Select
Less than $25000
$25000 – $49999
$50000 – $74999
$75000 – $99999
$100000 – $200000
$200000
Your Partners Annual Income
Please Select
Less than $25000
$25000 – $49999
$50000 – $74999
$75000 – $99999
$100000 – $200000
$200000
Your Highest Level of Education
Please Select
Less than high school
High School
College
Graduate School
Post Graduate School
Partners Highest Level of Education
Please Select
Less than high school
High School
College
Graduate School
Post Graduate School
What is your relationship status?
Married
Not Married
How many years have you been together?
Less than a year
1 - 3 years
3 - 5 years
5 - 10 years
10 - 20 years
20 or more years
How satisfied are you with your partners emotional support?
1
2
3
4
5
How satisfied you are with the respect and admiration received from your partner?
1
2
3
4
5
How satisfied are you with your partners financial support?
1
2
3
4
5
How satisfied are you with your sex life?
1
2
3
4
5
How satisfied are you with the time you spend together with your partner?
1
2
3
4
5
How often do you argue about the following reasons?
Rows
Daily
Weekly
Monthly
Rarely
Never
Money
Friends
Parents
Household chores
Children / Pets
Phone Usage
Responsibilities
Time Spent Together
Intimacy
Each Others Appearance
How fast are your relationship issues resolved or forgiven?
Immediately
Next day
At least a week
Always hold a grudge
From 1 to 10 how would you rate your relationship?
1
2
3
4
5
6
7
8
9
10
Submit
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