Personal Intimacy Questionnaire

Personal Intimacy Questionnaire

See where you rank in the various forms of Intimacy. This assessment is best done on a computer or tablet.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Would you like an Intimacy therapist to contact you? If not, please type "No"*
Would you like to sign up for the Newsletter?*

YesNo
Self Intimacy
I feel that I maintain my sense of self and personal identity even though I have a partner in life.*

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5

1 is Never, 5 is Always
I spend adequate time taking care of myself, my personal hygiene, and my health (physical, mental, emotional).*

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5

1 is Never, 5 is Always
I can say that I am putting my best foot forward as it pertains to living the life that I want and doing what is most important to me.*

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5

1 is Never, 5 is Always
Spiritual Intimacy
I feel that I have spent adequate time determining what my spiritual beliefs are.*

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1 is Never, 5 is Always
I spend adequate time practicing my spirituality and spiritual beliefs.*

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1 is Never, 5 is Always
I feel that I maintain my sense of self and personal identity with or without a partner in life. *

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1 is Never, 5 is Always
I try my best to follow my spiritual beliefs*

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1 is Never, 5 is Always
Emotional Intimacy
I feel like I understand my emotions, where they come from, and how to manage them.*

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5

1 is Never, 5 is Always
I am capable of allowing and feeling uncomfortable emotions and getting past them.*

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1 is Never, 5 is Always
When I am unable to handle my emotions, I choose to utilize safe coping strategies or stress management techniques.*

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1 is Never, 5 is Always
I can express my emotions to others without getting angry.*

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1 is Never, 5 is Always
I feel that my emotions are validated by my loved ones.*

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1 is Never, 5 is Always
Sexual Intimacy
I have set non-negotiable boundaries and rules over how my body is to be treated by others, whether physically, sexually, verbally, or emotionally.*

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1 is Never, 5 is Always
I know my sexual preferences, likes, dislikes, and what I am curious about or open to trying with preferred individuals (homo vs. hetero vs. non-identified, serious vs. casual)*

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1 is Never, 5 is Always
I can identify at least 3-5 positive attributes that I bring to sexual intimacy.*

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1 is Never, 5 is Always
I can be sexually satisfied without the use of alcohol or drugs.*

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5

1 is Never, 5 is Always
Financial Intimacy
I feel like I have a healthy relationship with money and finances.*

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5

1 is Never, 5 is Always
I have a financial plan for my future, for both financial success and managing potential financial crises.*

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1 is Never, 5 is Always
I know what I value most, financially, in choosing a partner. *

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1 is Never, 5 is Always
Friendship Intimacy
I feel that I show up equally for the friendships that show up for me the most.*

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1 is Never, 5 is Always
I am content and feel valued for who I am in my friendships. *

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1 is Never, 5 is Always
Over my adult years, I have at least 3 good friends I can depend on for support. *

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1 is Never, 5 is Always
Community Intimacy
I am confident in the amount of time I take to give back to my community.*

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5

1 is Never, 5 is Always
I enjoy the level at which I participate in advocacy, charity, outreach, social justice, and/or community initiatives.*

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1 is Never, 5 is Always
I am confident that both my digital presence and usage are productive, meaningful, and positively impactful on the digital community.*

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1 is Never, 5 is Always
Work Intimacy
I feel that my current job and/or professional line of work “suits” my unique skills, personal and professional attributes.*

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5

1 is Never, 5 is Always
I spend time on a routine basis checking in with my career and professional goals to make sure I stay on track with what I want out of my career and professional endeavors.*

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1 is Never, 5 is Always
I am confident in how I “show up” at work; this includes my professional appearance, how I take care of my workspace, and how well I interact and connect with coworkers, clients, vendors, and service providers.*

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1 is Never, 5 is Always
Recreational Intimacy
I spend adequate time taking part in activities that bring me joy and that allow me to authentically self-express.*

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1 is Never, 5 is Always
I spend adequate time admiring nature and natural elements and beauties of the world, life, and human existence.*

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1 is Never, 5 is Always
I partake in sufficient activities that allow me to relieve stress safely, wisely, and effectively.*

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1 is Never, 5 is Always
I can have fun without the use of alcohol or drugs.*

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1 is Never, 5 is Always
Humor Intimacy
It is easy for me to experience joy and laughter.*

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1 is Never, 5 is Always
I spend adequate time experiencing joy and laughter.*

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1 is Never, 5 is Always
I know how to identify what brings me joy and laughter.*

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1 is Never, 5 is Always
Linguistic Intimacy
I spend adequate time learning and stimulating my mind and brain.*

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1 is Never, 5 is Always
I make the effort to learn about new things, stay current on relevant affairs, and increase my breadth of knowledge.*

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1 is Never, 5 is Always
I feel adequate in my ability to communicate my feelings, thoughts, and ideas to others.*

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1 is Never, 5 is Always
I feel adequate in my ability to forgive others for mistakes and I am also worthy of forgiveness for my mistakes.*

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1 is Never, 5 is Always
I feel confident in how I manage crises and conflicts that arise in my life.*

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1 is Never, 5 is Always
Parenting Intimacy
I know where I stand on the topic of parenting; (want/don’t want children, adoption/surrogacy, natural/unnatural)*

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1 is Never, 5 is Always
I am confident in my financial, social, and emotional abilities to be a parent.*

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1 is Never, 5 is Always
I know what I value most in parenting.*

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1 is Never, 5 is Always

Personal Intimacy Questionnaire

Self Intimacy

Spiritual Intimacy

Emotional Intimacy

Sexual Intimacy

Financial Intimacy

Friendship Intimacy

Community Intimacy

Work Intimacy

Recreational Intimacy

Humor Intimacy

Linguistic Intimacy

Parenting Intimacy