Couples Questionnaire

These questions are designed to save time during the assessment sessions and to give you insight into your relationship. Each person is required to complete this information separately. Copy and paste the questions into a word document and then take some time to complete this questionnaire. It will help to remind you of what brought you together and what may be driving you apart. You do not need to share your answers with each other.  Please email your completed questionnaire back to me before our first session.

  1. Name
  2. Address and contact number
  3. Email address
  4. Age
  5. Are you currently working?
  6. If yes, what is your position and are you satisfied with your job?
  7. Relationship status
  8. Partner’s name and occupation
  9. Children (list names and ages)
  10. Who are the members of your family of origin? List names, ages and your relationship with the people you lived with growing up.
  11. How long have you and your partner been together (dating, living together, married)?
  12. Briefly describe the problems that have led you to look for couples therapy at this time.
  13. When did you first start noticing these problems?
  14. What steps, if any, have you taken to try to resolve these problems?
  15. Have you been in therapy before (individual, couples or family therapy)?
  16. Was your previous therapy helpful? If not, why?
  17. Are you taking any medication? If yes, please list and state purpose for the medication.
  18. Do you have any significant physical or mental health challenges? Please list.
  19. How would you describe your mood currently?
  20. Describe your use of alcohol and other mood altering drugs (how often, how much and under what circumstances you use them).
  21. Do you have a history of physical, sexual, emotional or verbal abuse?
  22. If you do, would you like to discuss this with me during an individual session?
  23. What are you hoping to achieve, if it is possible, in couples therapy?
  24. What personal growth do you wish for?
  25. What initially attracted you to your partner?
  26. How did you decide to be partners?
  27. What do you find most fulfilling about your relationship?
  28. What was the very beginning of your relationship like and how long did this phase last?
  29. What was your first disillusionment? What happened? How did your resolve it?
  30. When do you feel least fulfilled in your relationship?
  31. In what ways are the two of you similar?
  32. In what ways are you different?
  33. How do you deal with tension in your relationship? What do you do when you are angry? What does your partner do when angry?
  34. Do arguments with your partner get too heated? If your answer is yes, what is the worst thing that happens?
  35. How do you resolve conflicts?
  36. How was conflict handled in your family when you were growing up?
  37. Do you spend time in activities away from your partner? If so, how often?
  38. Do you spend time alone with people who are not mutual friends?
  39. Does this create conflict in your relationship?
  40. How comfortable are you doing activities away from your partner?
  41. How comfortable are you with your partner doing things away from you?
  42. How safe do you feel expressing your innermost thoughts and feelings to your partner?
  43. How do you ask for emotional support from your partner when you are feeling vulnerable?
  44. Do you expect to get it?
  45. Would your partner say that you are emotionally responsive to your partner’s vulnerability? Explain.
  46. Do you take an active, energetic role in nourishing your relationship? How?
  47. Does your partner do the same? How?
  48. Would you like to discuss anything about sex or sexuality in therapy? If you would, please give a brief outline of what you would like help with.
  49. Do you support your partner’s development as an individual? How?
  50. Do you support your partner’s growth as an individual even when you don’t agree? How?
  51. What kind of relationship would you like to create with your partner?
  52. Why is this kind of relationship important to you?
  53. What will be required of you (not your partner!) to bring about the kind of relationship you want?
  54. Are you willing to do homework in between sessions?
  55. Do you believe that your partner is giving at least 50% to your relationship?
  56. Do the two of you have joint commitments to projects, work activities or social causes? If so, what?
  57. Did you deliberately decide to create something together in one of these areas?
  58. Does this project seem to add or detract from the bond between you?
  59. If your relationship were a drama, movie or book, what would it be called? How would it end?
  60. Is there any further information you wish me to know?

Thank you for taking the time to complete this form. All information will be treated in confidence.

Thanks to Dr. Ellyn Bader and Dr. Peter Pearson from the Couples Institute for many of these questions.

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Nancy St. John