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.





















Have you had an affair(s)?
Yes
No

If yes, does your partner know?
Yes
No







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