Please rate by circling the best answer to each question as it applies to you individually and not your spouse
or as a couple. 1 is the worst and 10 is the best.

1. Communication skills: 1 2 3 4 5 6 7 8 9 10

2. Trust in my partner: 1 2 3 4 5 6 7 8 9 10

3. About how often on average do I initiate intimate (hugs, kisses, holdiing hands, etc.) and/or sexual contact
     with my partner/spouse? a ) Weekly, b) monthly, c) bi-monthly, d) a few times a year, e) not at all.

4. If I were caught in a room with a fire breathing dragon, would I, a) take out my sword and try to slay
     the dragon, or b) run out of the room.

5. When I get into arguments with my partner/spouse, do I, a) insist on talking about it or
    b) sweep the issue under the rug and talk about it later or c) don't talk about it at all.

6. How often do I suggest to my partner/spouse that we go on a date? a) Frequently, b) occasionally,
    c) sometimes, d) not at all.

7. Most of the time, when I argue I, a) yell and name call, b) just raise my voice in frustration and maybe
    say things I don't mean, c) make an effort to talk calmly, d) walk away.

8. How often do I talk to my partner/spouse about my day and perhaps with work, friends, etc.,
    or problems that I may have experienced in other areas outside the relationship?
   a) Frequently, b) sometimes,c) Infrequently d) not at all.

9. How often do I argue over money? a) Frequently, b) sometimes, c) infrequently, d) not al all.

10. How well do I listen to my partner/spouse when he/she wants to talk to me?
      1, 2, 3, 4, 5, 6, 7, 8, 9, 10

11. How often do I say, "I love you"? a) Everyday, b) sometimes, c) infrequently, d) never

12. What is my favorite way to express that I care about my partner/spouse? a) Gift giving, b) doing nice things,
     c) helping around my home, d) saying nice things, e) other_______________________________

13. How satisfied am I in the following areas? Please mark a number 1 to 10 next to each. 1-worst, 10-best.

Intimacy________________
Sex____________________
Communication__________
Money__________________
Recreation and Fun________
Family, (other than partner/spouse, children)__________________
Conflict resolution_________
Friendships/support network_____________
Work/Career_____________
Health and Physical self care_____________

What barriers have interfered in those areas that are a 5 or less.

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What would you like to see happen in therapy that would help you and your spouse?

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