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Couple Screening Form
Lindsay Swan
2018-05-25T14:08:59+00:00
Couple Screening Form
Name:
*
check all that apply
MOODS (ex. irritability, depression, etc.)
My moods are a problem to the relationship.
My partner's moods are a problem to the relationship.
How so?
*
ALCOHOL and SUBSTANCE USE
My use of alcohol is excessive.
My use of prescription or illegal drugs is a problem.
My partner's use of alcohol is excessive.
My partner's use of prescription or illegal drugs is a problem.
AGGRESSION
My temper adversely affects our relationship.
I have been verbally abusive to my partner.
I have been physically abusive to my partner.
My partner's temper adversely affects our relationship.
My partner has been verbally abusive to me.
My partner has been physically abusive to me.
Our fights and arguments are very destructive to our relationship.
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
.
How Strongly Do You Agree?
I feel disorganized by all this negative emotion.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I can't think straight when my partner gets so negative.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
Talking things over with my partner only seems to make them worse.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I have little confidence that we can discuss a significant problem without fighting.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I am basically unhappy with my relationship.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I have often felt like leaving my partner.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I often don't feel close to my partner.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I'm not satisfied with our sex life.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I feel lonely in our relationship.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I feel we are disconnected.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
My partner and I live pretty separate lives.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
I confide in a special person outside of our relationship.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
Who?
*
There are specific events in our relationship that I am having trouble getting over.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
What?
*
In spite of our problems, I believe that my partner really cares about me.
*
0% Not at all
25% Slightly
50% Moderately
75% Very
100% Extremely
Δ