Couple Screening Form

Name:*

check all that apply

MOODS (ex. irritability, depression, etc.)

How so?*

ALCOHOL and SUBSTANCE USE

AGGRESSION

AFFAIRS

I have had an affair during our relationship (or an inappropriate outside relationship).
I am currently having an affair (or an inappropriate outside relationship).
My partner has had an affair during our relationship (or an inappropriate outside relationship).
My partner is currently having an affair (or an inappropriate outside relationship).

How committed are you to staying in the relationship? (by percent)*

Please enter a number from 0 to 100.

Overall how satisfied are you now with your relationship? (by percent)*

Please enter a number from 0 to 100.

I feel disorganized by all this negative emotion.*

I can't think straight when my partner gets so negative.*

Talking things over with my partner only seems to make them worse.*

I have little confidence that we can discuss a significant problem without fighting.*

I am basically unhappy with my relationship.*

I have often felt like leaving my partner.*

I often don't feel close to my partner.*

I'm not satisfied with our sex life.*

I feel lonely in our relationship.*

I feel we are disconnected.*

My partner and I live pretty separate lives.*

I confide in a special person outside of our relationship.*

Who?*

There are specific events in our relationship that I am having trouble getting over.*

What?*

In spite of our problems, I believe that my partner really cares about me.*