COUPLES QUESTIONNAIRE:

Thank you for taking the time to fill out the following couples questionnaire. Your answers are confidential between your therapist & you and will be sent to your therapist on a secure HIPAA compliant platform.

Client Name

Date of Form Completed:

Client E-Mail

My relationship status is currently:

Married

Dating/Relationship

Separated

How long have you been in a relationship or married?

On a scale of 1-10, please rate your current level of relationship happiness. (1=Dissatisfied, 10=Extremely Happy)

How did your significant other & you meet?

If married, how long did your significant other date before getting married?

List certain qualities your significant other has that made you fall in love with him/her.

What are your biggest strengths as a couple?

Describe the main problem areas in your relationship / marriage & how often they occur:

As you think about the primary reason that brings you to counseling, how would you rate its frequency and your overall level of concern at this point in time?

No Concern

Little Concern

Moderate Concern

Serious concern

Please describe how you usually communicate with your significant other during times of conflict:

How does your significant other communicate during conflict? Are there ways you wish he/she would improve?

List areas you feel you can work on to help improve your relationship:

Have you tried to improve your relationship in the past & it hasn't worked? If so, please list examples of unsuccessful attempts.

Do you know your significant other's love languages? If so, how have you tried to show your significant other your love them through their desired love language?

Is their a certain love language you have that you wish your significant other would consider more often?

Please describe how you envision your relationship being in the future:

Is there any additional information you would like your therapist to know?