Relationship Emotional Safety Assessment

Relationship Emotional Safety Questionnaire

Assess how emotionally safe your relationship feels using reflection prompts and rating tables. Complete honestly based on your experience over the past 4–6 weeks, and revisit periodically to track changes over time.
Relationship Information
Name

First NameLast Name
Date Completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Partner's Name

First NameLast Name
Emotional Safety in Relationships

Please take a moment to study "Emotional Safety in Relationships" handout (as detailed above, you can download it by clicking on the image link) and then rate how emotionally safe you currently feel (below):
How emotionally safe does your relationship currently feel?

1

2

3

4

5

6

7

8

9

10

1 is Not Safe, 10 is Extremely Safe
Understanding My Emotional Safety

Emotional safety is the experience of being able to be yourself in a relationship without fear of ridicule, attack, rejection, dismissal or abandonment.

Emotional Rating

Rows	Never	Rarely	Sometimes	Very Often	Always
1. I can be honest with my partner
2. I can disagree without fear
3. I can express difficult emotions
4. I can ask for what I need
5. I can say no without guilt
6. I can make mistakes and still feel accepted
7. I can be my authentic self without fear of judgement, rejection or criticism
8. I can be imperfect

What stands out for you when answering these questions? (Please describe your feelings or thoughts)
What Helps Me Feel Safe

My partner helps me feel emotionally safe when they (tick as appropriate)

Rows	Tick as appropriate
9. Listen without interrupting
10. Stay calm when they are upset
11. Stay calm when I am upset
12. Ask curious questions
13. Give me time to think
14. Respect my boundaries
15. Accept differences
16. Take responsibility when they hurt me

Please describe what your partner does that helps you to feel emotionally safe? (if not included in the list above)
What I Feel Threatens My Emotional Safety
I feel emotionally unsafe when? (Please describe choices you make or behaviours you exhibit that contribute to you feeling emotionally unsafe)
My partners choices or behaviours that make me feel the most unsafe are? (Please describe choices your makes or behaviours they exhibit that contribute to you feeling emotionally unsafe)
My Emotional Safety Traffic Lights Reflection Questions

Please take a moment to study "The Emotional Safety Traffic Light" handout (as detailed above, you can download it by clicking on the image link) then please answer the questions below:
Green Zone - What percentage our your time do you typically spend in the Green Zone?
Green Zone - What typically happens to move you from the Green Zone to the Amber Zone?
Amber Zone - What are the earliest signs that your emotional safety is becoming threatened?
Amber Zone - What typically happens to move you from the Amber Zone to the Red Zone?
Red Zone - What do you tend to do when you reach the Red Zone?
Red Zone - What does your partner tend to do when they reach the Red Zone?
Communication Safety

Communication Safety Rating

Rows	Never	Rarely	Sometimes	Very Often	Always
17. My partner listens to understand.
18. I feel heard when I speak.
19. Difficult conversations feel safe.
20. We communicate without blame.
21. My partner is curious about my experience.
22. I can express needs openly.
23. I can say no.
24. Conflict leads to understanding.

Emotional Connection

Rows	Never	Rarely	Sometimes	Very Often	Always
25. I feel emotionally connected.
26. I feel understood.
27. My partner makes an effort to understand me.
28. I can be vulnerable.
29. I feel empathy from my partner.
30. We repair after conflict.
31. I trust my partner's intentions.
32. We move towards one another during difficult times.
33. My partner is curious about my experience.
34. We seek understanding before judgement.
35. We assume positive intent.

What helps you feel emotional connected to your partner?
Nervous System Relationship Safety

When emotional safety is present our nervous systems can regulate, we feel calmer, more connected and more open. We we emotional safety is absent we become dysregulated and can feel anxious or fearful.

You nervous system safety rating

Rows	Never	Rarely	Sometimes	Very Often	Always
36. I feel calm around my partner.
37. I need to protect myself emotionally.
38. I feel safe sharing difficult thoughts with my partner.
39. My partner responds supportively when I am distressed.
40. I feel safe asking for reassurance.
41. I recover quickly after conflict.
42. My partner helps me feel grounded.
43. Being with my partner feels emotionally settling.

When you feel emotional unsafe or overwhelmed how often do you experience the following?

Rows	Never	Rarely	Sometimes	Very Often	Always
44. I withdraw.
45. I shut down.
46. I become defensive.
47. I become critical.
48. I feel misunderstood.
49. I feel judged.
50. I feel rejected.
51. I avoid difficult conversations.
52. I feel lonely.
53. I become emotional
54. I become irritable
55. I need reassurance
56. I lose access to words
57. I need to move
58. I become logical\/problem solving
59. I apologise repeatedly

When your partner is overwhelmed or you experience them as emotionally unsafe they typically would what?

Rows	Never	Rarely	Sometimes	Very Often	Always
60. Withdraw.
61. Shut down.
62. Become defensive.
63. Become critical.
64. Rejected me.
65. Avoid difficult conversations.
66. Complain of feeling lonely.
67. Become emotional
68. Become irritable
69. Need reassurance
70. Lose access to words
71. Need to move
72. Become logical\/problem solving
73. Apologise repeatedly
74. Complain about being missunderstood

Email (please enter your email address to receive a copy of your competed form)
example@example.com
Should be Empty:

Relationship Emotional Safety Questionnaire