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COUPLES ASSESSMENT QUESTIONNAIRE
This questionnaire is to be completed by both parties individually, on two separate documents.

To the best of your ability, please answer all of the questions. All of the information that you provide in this questionnaire will remain strictly confidential.

Email address *
Full Name *
Your answer
Date of birth *
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Nationality *
Your answer
Country of Residence *
Your answer
Your Partner's name *
Your answer
Presenting problem: In your opinion, what are the reasons you are consulting as a couple at this time? Describe in as much detail as possible the issues you have with your partner, when they began etc... *
Your answer
What do you expect out of this therapy? What are your goals? *
Your answer
History of your current relationship How long have you and your partner been together? *
Your answer
What are your living arrangements? *
Your answer
What was the very beginning of your relationship like? How long did this phase last? *
Your answer
What initially attracted you to your partner? *
Your answer
What are the things you like most about your relationship? What are your sources of pleasure as a couple? *
Your answer
What are the top 3 things you wish to change in your relationship? When do you feel most frustrated in your relationship? *
Your answer
In what important ways are the two of you similar? Different? What do the two of you share in common? *
Your answer
Have you had therapy or couple's counselling in the past? If so, when? Explain what was helpful and what was not. *
Your answer
Percentage committed to staying in your relationship : *
Your answer
What traits do you appreciate in your partner? *
Your answer
What traits do you think your partner appreciates in you? *
Your answer
Do you feel supported by your partner. If so, how and when? *
Your answer
Do you feel that you provide your partner with support or encouragement? How? *
Your answer
Relationships/ Family History How would you describe the home in which you were raised? *
Your answer
Describe your relationship in brief with each member of your family i.e. father, mother, siblings, children. Including between them. *
Your answer
Handling Conflicts Our fights and arguments are very destructive to our relationship *
Required
How often do you argue? *
Your answer
What do you most often argue about ? *
Your answer
What do you do when you are angry? What does your partner do? *
Your answer
How long do you stay mad at each other? Who is the first to attempt to make things better? How do you resolve conflict? *
Your answer
Describe your most recent argument. How did it start? How did it end? *
Your answer
Do you ever feel like leaving your partner? *
Required
Have there been any incidents of physical violence or threat of violence? If yes, describe. *
Your answer
Do you or your partner have difficulties with alcohol or substance abuse? If yes, describe *
Your answer
Has there been any infidelity in your relationship? If yes, describe *
Your answer
Intimacy Are you sexually active with your partner? *
How satisfied are you with your sex life with your partner? *
Completely Unsatisfied
Completely Satisfied
Who initiates sex most often? *
Required
Do you communicate well? *
Required
How open are you in expressing your innermost thoughts and feelings with your partner ? *
Totally Closed
Totally Open
How connected do you feel to your partner *
Completely Separate
Completely Attached
Social List some social activities you engage in as a couple, please include the frequency of each. *
Your answer
What social activity do you enjoy the most together? *
Your answer
How comfortable are you doing activities away from your partner? How comfortable are you with your partner spending time away from you? *
Your answer
Do you confide in a special person outside of your relationship? If so, who? Describe your relationship *
Your answer
Name your joint commitments to goals, projects, work etc. *
Your answer
Other Is there anything else you feel is important to share right now? *
Your answer
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