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
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 physicalillnesses, 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
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