PRE-COUNSELING COUPLES / MARRIAGE QUESTIONNAIRE
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1 PRE-COUNSELING COUPLES / MARRIAGE QUESTIONNAIRE Name: BOTH PARTNERS NEED TO COMPLETE THIS QUESTIONNAIRE SEPARATELY AND INDEPENDENTLY. PLEASE BRING TO YOUR FIRST SESSION, BUT DO NOT SHARE YOUR ANSWERS WITH YOUR SPOUSE / PARTNER As you think about the primary reason that brings you to couples / marriage counseling, how would you rate your overall level of concern at this point in time? No concern (counseling was my partner s idea) Little concern Moderate concern Serious concern Very serious concern Rank order the top three concerns that you have in your relationship with your partner (#1 being the most problematic): Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems? Yes If yes, who? Me Partner Both of us If married, have either you or your partner consulted with a lawyer about divorce? Yes If yes, who? Me Partner Both of us Have either you or your partner struck, physically restrained, used violence against or injured the other person? Yes If yes, please answer the following: Who was the aggressor? Me Partner Both of us What happened? Were the police involved? Yes Was a restraining order filed? Yes Was Child Protective Services (CPS) involved? Yes If so, what happened as a result of involvement by CPS? How often did or has this occurred in the relationship? Is this physical aggression / violence still occurring in the relationship? Yes If yes, how often does this occur? Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 1 of 6
2 EARLY DYNAMICS AND CHARACTERISTICS OF YOUR RELATIONSHIP WITH EACH OTHER Please indicate what you believe was the primary reason why you and your spouse / partner got married or began to cohabitate (check any and all that apply)? We were crazy in love We had a child out of wedlock I / my partner needed to be rescued or escape a difficult situation (e.g., family / previous partner) For financial security and stability Because I felt my spouse / partner needed me Because I did not know how to say No What was the very beginning of your relationship like with your spouse / partner? And how long did this phase last? What was your first relationship disillusionment / disappointment with your spouse / partner? What happened and how did you resolve it? Did this lead to any changes in your relationship? Please explain. CURRENT RELATIONSHIP STRENGTHS, NEEDS, AND ISSUES Please rate your current level of relationship happiness by circling the number which corresponds with your current feelings about the relationship. Extremely Very Unhappy Somewhat Neither Happy Somewhat Very Happy Everything Is Unhappy Unhappy Nor Unhappy Happy Perfect How would you rate your current level of stress in your life (e.g., roles / responsibilities, relationships, work, finances, etc.)? No Stress Moderately Extremely At All Stressed Stressed To what degree does your family and / or friends support you as a couple? Extremely Very Somewhat Neither Somewhat Very Supportive Extremely Unsupportive Unsupportive Unsupportive Supportive Nor Supportive Supportive Unsupportive Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 2 of 6
3 To what degree do the two of you share a similar basic worldview / set of values? Extremely Very Dissimilar Somewhat Neither Similar Somewhat Very Similar Extremely Dissimilar Dissimilar Nor Dissimilar Similar Similar Rate how open you are in expressing your innermost wants, thoughts, desires, and feelings to your spouse / partner? Totally Closed Very Closed Somewhat Neither Open Somewhat Open Very Open Totally Open Closed Nor Closed Please indicate the approximate extent of agreement or disagreement between you and your spouse / partner on the following items by checking a response for each item. Handling finances Recreation / hobbies / leisure time Demonstrations of affection Parenting / discipline Outside friendships Ways of dealing with in-laws Physical intimacy / sexual relations Philosophy of life / core values Conventionality (right, good, or proper conduct and behavior) Social causes / politics Other (please list): Always Agree Almost Always Occasionally Frequently Always Disagree Agree Disagree Disagree How are the two of you similar? How are you different? When did you first become aware of significant differences between the two of you? Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 3 of 6
4 When you feel like you want support or encouragement from your partner, do you get it? If yes, explain how. When your partner wants support or encouragement from you, do you feel that you give it? If yes, explain how. Do you support your partner s development as an individual? If yes, explain how. What are your biggest strengths as a couple (include any that you believe also help with resolving conflicts or disagreements)? When do you feel most gratified / satisfied / validated in your relationship? What is one thing that your spouse or partner does very well and you would love for them to keep doing it? What is one thing that your spouse or partner is doing OK and you would like them to improve? What is one thing that your spouse or significant other is doing that is killing the relationship and you would like them to stop? When disagreements arise, they usually involve (left column is how you feel about your partner; right column is how you think your partner feels about you): My partner becomes very angry / over-reactive My partner tends to blame me for our problems My partner tends to withdraw affection from me My partner is often critical of me My partner does not appreciate me My partner does not respect or like me My partner does not understand my needs My partner feels I become very angry / over-reactive My partner feels I blame them for our problems My partner feels I tend to withdraw my affection My partner feels I am often critical of them My partner often feels unappreciated by me My partner feels I do not respect or like them My partner feels I do not understand their needs Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 4 of 6
5 When disagreements arise, they usually result in (check any and all that apply): Me giving in and / or apologizing Me blowing up Me ignoring my partner s feelings and concerns My partner giving in and / or apologizing My partner blowing up My partner ignoring my feelings and concerns Overall, I tend to view my spouse / partner as being: A complainer / is negative or pessimistic Responsible and helpful Thoughtful and caring Positive about life / challenges Irresponsible or unhelpful Not thoughtful or caring My spouse / partner and I generally prefer (select one answer about yourself and one about your spouse / partner): My spouse / partner prefers to be on the go My spouse / partner prefers to stay at home I prefer to be on the go I prefer to stay at home My spouse / partner and I engage in outside interests together: All of them Some of them Very few of them None of them When it comes to spending time together or apart, I would like to: Spend more quality time together Go on more dates together Participate in more recreational activities together Travel more / go on more vacations together Spend more time together with our families Spend more time together with our mutual friends Spend more time apart with our separate friends Have more autonomy / do more things independently If I had my life to live over again, I believe I would: Marry or partner with the same person Marry or partner with a different person Date longer before marrying / cohabitating Not marry or cohabitate with a partner at all How often to you ever wish you had not married or weren t in a domestic partnership? Frequently Occasionally Rarely Never What roles / responsibilities do you feel stuck in, uncertain about, or out of balance for you at this moment in your life, work, and / or relationship? What have you already done to deal with the difficulties in your relationship? Please make at least one suggestion as to something you could personally do now to improve the relationship regardless of what your partner does. Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 5 of 6
6 PHYSICAL INTIMACY / SEXUAL RELATIONSHIP Have you or your spouse / partner been unfaithful to each other (i.e., emotionally, physically, or both)? Yes If yes, who was unfaithful? Me Partner Both of us When was the first incident? Was this the only time you or your spouse / partner were unfaithful? Yes Is the affair still ongoing? Yes Does your partners / spouse know? Yes Rate how enjoyable is your sexual relationship with each other? Terrible Very Unpleasant Somewhat Neither Pleasant Somewhat Very Pleasant Fantastic Unpleasant Nor Unpleasant Pleasant How satisfied are you with the frequency of physical intimacy / sexual relations with each other? Way Too Often A Bit Too Often About Right A Bit Too Infrequent Way Too Infrequent How many times on average in a month are you physically intimate / have sex with each other? What do you find most satisfying about physical intimacy / sex with each other? What do you find least satisfying about it? How has your sexual relationship changed since you were first together? What is one thing that you wish was different about your sexual relationship? THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. PLEASE BRING THIS WITH YOU DURING YOUR FIRST APPOINTMENT. PLEASE NOTE THAT YOU WILL BE ASKED TO TALK ABOUT YOUR ANSWERS IN SESSIONS BUT YOUR SPOUSE / PARTNER WILL NOT BE SHOWN THIS FORM. Pre-Counseling Couples / Marriage Questionnaire for Katherine E. Walker, PhD, LPC, NCC, BCIA-C Page 6 of 6
SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
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