Couples Questionnaire Form Couples Questionnaire Please note any information you share in any form is not kept confidential from your partner, as long as, you and your partner are in couples counseling together at BreakThru. Name Date What is the problem that led you to decide to come to therapy? How long have you and your partner been together? In what form (i.e., married, dating, living together)? What initially attracted you to each other? How did you decide to get married or live together? What do you find most fulfilling about your relationship? What was the very beginning of your relationship like? How long did this phase last? What was your first disillusionment? What happened and how did you resolve it? When do you feel least fulfilled in your relationship? In what significant ways are the two of you similar? Different? What methods have you worked out to accommodate or compromise on your differences? Do you spend time in activities away from your partner? If so, how often? Do you spend time alone with people who are not mutual friends? Does this create a conflict in your relationship? How comfortable are you in doing activities away from your partner? How comfortable are you with your partner doing things away from you? How safe do you feel expressing your innermost thoughts and feelings to your partner? How do you ask for emotional support from your partner when you are feeling vulnerable? Do you expect to get it? Would your partner say that you are emotionally responsive to his/her vulnerability? Explain. Do you take an active, energetic role in nourishing the relationship? Does your partner do the same? How? Do you support your partner’s development as an individual? How (give example)? Do you support his/ her growth as an individual even when you don’t agree? How (give example)? Do you believe that your partner is giving at least 50% to the relationship? Do the two of you have joint commitments to projects, work activities, or social causes? If so, what? Did you deliberately decide to create something together in one of these areas? Does this project seem to add or detract from the bond between you? Have you had an affair(s)? Yes No If yes, does your partner know? Yes No How long has it lasted? Give reasons you pursued affair. As we can’t change anyone but ourselves, what are the goals you need to set for yourself to help positively impact your relationship? What impact do your children have on your relationship? What impact do your and your spouse’s jobs have on your relationship? What impact do your and your spouse’s jobs have on your relationship? Place an "X" by any of the below stressors that are involved in your relationship: Alcohol / drug abuse Pornography or Sexual Addiction Gambling Infertility Controlling Behaviors Physical violence between spouses Past or current sexual abuse Threat(s) or attempt(s) of suicide Finances Affair (s) Abortion (s) Other Other
