Couples Relationship Questionnaire
Please submit at least 3 days prior to first session
Your Name
*
First Name
Last Name
Partner / Spouses Name
*
First Name
Last Name
Relationship Status
*
Married
Seperated
Partnered (live together)
Divorced
Partnered (do NOT live together)
Other
If married, when did you get married? If seperated, please indicate the date of seperation.
TOTAL time you have been in relationship with your partner.
How many relationships have you been in prior to current relationship?
*
0 - 3
3 - 5
5 -10
10 or more
How many children do you have? Their names and ages? Are they from your current relationship?
*
Rank the level of importance you feel for the following aspects
Rows
Not Important
Somewhat Important
Important
Very Important
Physical Connection
Friendship
Honesty
Friendliness
Monogamy
Personal Space
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What are 3 things you are grateful for about your partner / spouse?
*
What are the issues you are struggling with now? Is this a recurring issue?
*
How long has this been occuring?
*
What are the strengths in your relationship? What do you love about your partner?
*
What are the stresses in your life at the current time?
*
Significant stresses over the course of your relationship.
*
What triggers you most about your partner. How do you react when you get triggered?
*
Dependencies past andpresent: alcohol, drugs, shopping, food, gambling, porn, sex, internet or anyothers.
*
Describe any physical illnesses, present and past.
*
What is happening in your sexuality with one another? Describe your sexual relationship over time?
*
Have either of you had an affair or sexual relationship outside the marriage/partnership? When and how long did it/they last? How was it handled?
*
Describe how relationships were modeled to you by parents, grandparents, or other influential persons in your life growing up.
*
What do you want outof couples’ work?
*
What else should we know?
*
Submit
Should be Empty: