RELATIONSHIP RECOVERY PATHWAY ASSESSMENT

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Consent & Acknowledgement* This field is required.Your responses will guide us toward the most supportive next step — whether for you individually or for your partnership. There are no right or wrong answers, only honest ones. Please answer as openly as you feel comfortable. This space holds no judgment — only care. All information is held in the strictest confidence.

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1. I currently feel emotionally overwhelmed by this relationship situation.* This field is required.

True

False

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2. I am unsure whether this relationship should continue.* This field is required.

True

False

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3. I genuinely want to rebuild trust and repair the relationship.* This field is required.

True

False

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4. Conversations between us often become emotionally reactive, explosive, or shut down quickly.* This field is required.

True

False

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5. I need clarity before making major decisions about the relationship.* This field is required.

TRUE

FALSE

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6. Despite the pain, I still believe healing together may be possible.* This field is required.

TRUE

FALSE

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7. Right now, emotional stability feels more important than solving everything immediately.* This field is required.

TRUE

FALSE

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8. Which statement best describes where you are right now?* This field is required.

A. I feel overwhelmed, unstable, or need help calming the situation first.

B. I am unsure whether the relationship should continue and need clarity.

C. I want to rebuild trust and work toward repair.

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You will receive your assessment results immediately by email after you click submit.

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First Name* This field is required.

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Phone Number* This field is required.

Please enter a valid phone number.

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Email Address* This field is required.

example@example.com

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Relationship Status* This field is required.

Individual

Couple

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I consent to receive appointment reminders, scheduling updates, and other practice-related communications via SMS/text message from Dr. Monique Thompson’s office. I understand that text messaging may not be a fully secure form of communication and that I am responsible for notifying the office if my mobile number changes or if I wish to revoke this consent. Standard messaging rates may apply based on my mobile carrier plan.

Opt out - I do NOT want to receive occasional text reminders or supportive resources

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I consent to receive appointment reminders, scheduling updates, and other practice-related communications via SMS/text message from Dr. Monique Thompson’s office. I understand that text messaging may not be a fully secure form of communication and that I am responsible for notifying the office if my mobile number changes or if I wish to revoke this consent. Standard messaging rates may apply based on my mobile carrier plan.* This field is required.

Yes

No