Relationship Health Test Form

Relationship Health Test Form

This form is to help determine the health of your romantic relationship and how much quality time you and your significant other share.
How much time do you share with your significant other?

A littlea fair amountnot enoughtoo muchthe exact right amountevery second of the daynone, they are a ghost or a figment of my imaginationOther
If it is not enough time, what is keeping you apart?

workschoolchildrenanother partnermoney problemsdistancedifferent schedulesvenereal diseaseOther
What can be done to improve this situation?

graduationchange jobskids will grow up some daywork more or lessget marriedsee doctorOther
What interests do you and your partner share?

moviesmusicnatureexercisecookingmuseumszooreadingsexdate nightstheatretravelingtime with friendstime with familyservice workreligionpoliticseducationpetscollectingpuzzlesLoch Ness MonsterOther
Are your needs getting met?

yesnomostlybarelyOther
If not, what would you like, want or need more of?
Are your partner's needs getting met?

yesnomostlybarelyOther
If not, what do they like, want or need more of?
How do you handle conflict in the relationship?

talkingice creamaddictionsavoidancearguingdramafightingyellingshoutingname callingaccusationsempty apologiessilent treatmentpassive aggressive behaviorspatienceunderstandinglisteningchanged behaviorscompromiseaffection / affirmationsexOther
How does your partner handle conflict in the relationship?

talkingice creamaddictionsavoidancearguingdramafightingyellingshoutingname callingaccusationsempty apologiessilent treatmentpassive aggressive behaviorspatienceunderstandinglisteningchanged behaviorscompromiseaffection / affirmationsexOther
How much do you enjoy your relationship?

a lotsomeneeds improvementa littlebarelyI could kill themthis is the last strawI mean it this time, if this test doesn't help I am leaving themI couldn't be happierOther
How much does your partner accept you?

completelymostlymoderatelynot muchconstant complainingI wish I was deadOther
Seriously, how committed are you to improving your relationship?

it's the most important thing in my lifeI am very committed and willing to changeit's worth a trythere is a pretty good chanceas long as it doesn't interfere with my favorite showsI drink often to escape itI cheat constantlythere is no hope, it's been over for months and I don't know how to tell them
Is there anything that you would like help talking to your partner about?
What would you like to say about this test?
Who are you willing to speak with? (if other, please add their name and email address)

Jeff RoundsSelyna BreezeOther
Name

First NameLast Name
Email
example@example.com
By submitting I hereby confirm that the information I have given above is true, and that I will be receiving an email response to my submission and an invitation to discuss the results with a nonprofessional member of Mixed Recovery.
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