Couple Therapy Questionnaire
Please complete the following questions to evaluate your need for couple’s therapy and to determine what areas are problematic in your relationship.
(1) Are you and your partner both committed to working out your relationship problems? ____
(2) Do you and your partner both feel that having a mediator/counselor would be a possible help with your relationship problems? ____
(3) How long have you and your partner been together or married? ____
(4) At what point in your marriage or relationship did your problem(s) begin? _________________________________________________________________________________________________________________________________
(5) If you and your partner are not married are you planning on getting married? ____
(6) Do you or your partner feel that your problems are due to a lack of trust? ____ If Yes, why? ______________________________________________________________________________________________________________________________
(7) Have you or your partner been unfaithful to one another? ____
(8) Do you and your partner have children that live with you? ____
(9) Have you or your partner ever attended couple’s therapy? ____
(10) Did you and your partner agree to couple’s therapy? ____
(11) Do you know another couple who have effectively completed couple’s therapy? _____
(12) Do you or your partner feel like your relationship is one sided? _____
(13) Are you and your partner willing to work through your problems no matter what it takes? _____
(14) Do you and your partner feel that you can forgive each other for any wrongs done between one another? _____
(15) Do you or your partner have problems with anger? _____
(16) Do you or your partner feel that your problems root from financial difficulties?
(17) Can you and your partner say honestly that you have respect for each other? _____
(18) How much time and effort are you and your partner willing to put into couple’s therapy? ___________________________
(19) Are you or your partner using drugs or alcohol daily? ______
(20) Are you and your partner sexually active? _____
