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Relationship Status: (check all that apply)
Married
Separated
Living Together
Living Apart
Divorced
Dating
Length of time in current relationship?
What do you hope to accomplish through counseling?
What have you already done to deal with the difficulties?
What are your biggest strengths as a couple?
Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship: (1 to 10)
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:
Have you received prior couples counseling related to any of the above problems?
Have either of you been in individual counseling before?
Yes
No
If so please give a brief summary of the concerns you addressed
Do either you or your partner drink alcohol or take drugs to intoxication?
Yes
No
If yes for either who how often and what drugs or alcohol?
Do you ever wish your partner would cut back on his/her drinking or drug use?
Yes
No
N/A
Comment
Have either your or your partner stuck, physically restrained, used violence against or injured the other person?
Yes
No
If yes, who, how often, and what happened?
Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?
Yes
No
If yes, who?
Me
Partner
Both of us
If married, have either you or your partner consulted with a lawyer about divorce?
Yes
No
If yes, who?
Me
Partner
Both of us
Do you perceive that either you or your partner has withdrawn from the relationship?
Yes
No
If yes, who?
Me
Partner
Both of us
How enjoyable is your sexual relationship? (1 to 10)
How satisfied are you with the frequency of your sexual relations? (1 to 10)
What is your current level of stress (in the relationship)? (1 to 10)
What is your current level of stress (overall)? (1 to 10)
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COUPLE SATISFACTION CHECKLIST
Rows
Very Dissatisfied
Moderately Dissatisfied
Slightly Dissatisfied
Slightly Satisfied
Moderately Satisfied
Very Satisfied
From the 13 items, Check 3 areas you most want to change
Degree of Closeness, Openness, Confiding, Sharing and Comforting
Expression of Affection and Caring
Satisfaction with Sexual Intimacy
Handling Conflicts & Arguments
Expression of Anger, Criticism, or Blame
Handling Family Finance
Handling of Parenting Issues
Handling of Household Tasks
Common Interests & Social Life
Degree of Respect & Admiration for Your Partner
Satisfaction with Your Role in the Relationship
Satisfaction with Your Partner's Role in the Relationship
Overall Satisfaction with Your Relationship
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