Couple Coaching Susan Denee

COUPLE COACHING ASSESSMENT

Goal: This short assessment aims to help you both identify areas in your relationship for improvement. As with any evaluation, the goal isn’t a complete or perfect snapshot and rating of every nuance within your relationship but rather a good opportunity for overall relationship reflection. So don’t stress out about the exact wording of these descriptions. Instead, give your overall impression of the relationship rates in each category based on the last three months of the relationship.
Personal Information:
Full Name*

First NameMiddle NameLast Name
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marriage Status*

MarriedSingleDivorcedWidowedSeparatedNever Married
Occupation*
Date of Birth*

MonthDayYear
Date
Phone Number*
E-mail*
example@example.com
Using a scale from 1 to 10 please describe your level of satisfaction in each of the items below. 1 being the lowest and 10 being the highest
COMMUNICATION - I feel our communication is grounded in honesty, compassion, and respect. We honor one another with our words. We do well in not hurting one another verbally with insults or passive-aggressive comments.*
LOVE LANGUAGE - As individuals, we each express and receive love in unique ways. You may have heard of the Love Languages, a book written by Gary Chapman. They are five languages in which we express or receive love. The five love languages are words of affirmation, quality time, physical touch, acts of service, or receiving gifts. Please score the following statement: I feel we understand what one another identifies with as their primary love language*
FINANCIAL - I feel we are aligned in our financial goals. We agree on our future vision for our economic security. We are open to discussing financial goals with each other. We have an agreement on how, when, and where to prioritize our spending*
APPRECIATION - I feel appreciated as a partner in this relationship. I think my efforts in making this relationship positive and fulfilling are recognized and respected.*
FUN - I feel we have fun together. We mostly agree on exciting opportunities to explore, travel, and enjoy. I like the way I feel when we plan our playtime together.*
ENCOURAGEMENT - I feel we encourage one another with words and actions of support regarding our individual dreams and aspirations. We are devoted to helping not only our relationship grow but also devoted to supporting one another in their personal growth.*
VISION - I feel we are aligned in our future vision for the relationship. We understand one another’s desires for the relationship.*
ACCEPTANCE - I feel I am aligned enough to fully accept my partner for exactly who they are, even when I feel I am witnessing their struggles.*
LISTENING - I feel I am heard when we have conversations, even challenging conversations. I believe we have good tools we consistently utilize to enhance our listening skills.*
INTIMACY - I feel we are congruent in our beliefs and definition of intimacy. We effectively communicate what is essential to each of us and respect one another’s desires and needs. We look forward to a satisfying intimacy with one another.*
BOUNDARIES - As individuals in a relationship, I feel we understand the effectiveness and usefulness of boundaries. We know why they are important and the necessity of honoring each other’s boundaries. *
Please provide additional insight and answer to your best capability the questions below
How would coaching enhance your relationship?*
What do you look forward to experiencing with your partner?*
What are one or two of your best memories with one another?*
What do each of you do professionally?*
What are some of your favorite leisure activities together?*
What relationship challenges are you experiencing? (You may not agree, please list individual experiences).*
As a team, what do you do well together? *
If you have children individually or together, what are their ages?*
Have you previously participated in couple coaching*
What are three things you would love to see grow within your relationship? (Please list for each person)*
Should be Empty:

COUPLE COACHING ASSESSMENT