Relationship Questionnaire

These questions are designed to save time during the assessment sessions and to give you insight into your relationship. If you are coming as a couple, 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.  Return your completed questionnaire back to me before our first session.

  1. Your name and age:
  2. Are you currently working? If yes, what is your position and are you satisfied with your job?
  3. If you have a partner, what is their name and occupation?
  4. If you have children, what are their names and ages?
  5. Who are the members of your family of origin? List their names and any relevant information about your relationship with each of the people you lived with growing up.
  6. How did your parents get along with each other?
  7. How was conflict handled in your family when you were young?
  8. Did anyone in your family suffer from mental health issues when you were growing up?
  9. Have you ever been in a relationship where there has been physical, sexual, emotional or verbal abuse?
  10. How long have you and your partner been together (dating, living together, married)?
  11. Briefly describe the problems that have led you to look for therapy at this time.
  12. When did you first start noticing these problems?
  13. What steps, if any, have you taken to try to resolve these problems?
  14. Have you been in therapy before (individual, couples or family therapy)? Was your previous therapy helpful? Please explain.
  15. Do you have any significant physical or mental health challenges? Please list.
  16. Are you taking any medication? If yes, please list and state the purpose for the medication.
  17. How would you describe your mood currently?
  18. Describe your use of alcohol and other mood altering drugs (how often, how much and under what circumstances you use them).
  19. What type of relationship you would like to create?
  20. Why is that kind of relationship important to you?
  21. What kind of partner do you aspire to be?
  22. How far are you now from being the kind of partner you aspire to be?
  23. What do you think will be required of you to become a more effective partner?
  24. How do you think that might be difficult for you?
  25. How motivated are you to work on yourself and make some of those changes?
  26. What would be the payoff directly to you if you were to make those changes?
  27. What initially attracted you to your partner?
  28. How did you decide to be partners?
  29. What was the very beginning of your relationship like? How long did this phase last?
  30. What was your first disillusionment? What happened? How did you resolve it?
  31. When do you feel most/least fulfilled in your relationship?
  32. In what ways are the two of you similar/different?
  33. How do you deal with tension in your relationship?
  34. What do you do when you are angry? What does your partner do when angry?
  35. Do arguments with your partner get too heated? If your answer is yes, what is the worst thing that has happened?
  36. How do you resolve conflicts?
  37. Do you spend time in activities away from your partner? If so, how often?
  38. Does this create conflict in your relationship?
  39. How comfortable are you with your partner doing things away from you?
  40. Do you support your partner’s development as an individual? How?
  41. How safe do you feel expressing your innermost thoughts and feelings to your partner?
  42. How do you ask for emotional support from your partner when you are feeling vulnerable? Do you expect to get it?
  43. Would your partner say that you are emotionally responsive to their vulnerability? Explain.
  44. In what ways do you nurture your relationship? What loving behaviours warm your partner’s heart?
  45. How do you spend time alone with your partner?
  46. Do you and your partner show physical affection by holding hands, hugging or touching each other?
  47. 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.
  48. What kind of relationship would you like to create with your partner?
  49. Why is this kind of relationship important to you?
  50. What will be required of you (not your partner!) to bring about the kind of relationship you want?
  51. Are you willing to do homework in between sessions?
  52. What is it about you that makes you not the easiest person in the world to live with?
  53. Have you started pursuing a lifestyle that excludes your partner?
  54. Do you and your partner have any joint commitments to projects, work activities or social causes? Do you share any pleasurable activities that you both like? If yes, describe.
  55. If your relationship were a drama, movie, or book, what would it be called? How would it end?

Before you finish, take a moment and write down any other information that may be relevant to your relationship. All information will be treated confidentially.

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Nancy St. John