Relationship Difficulties

Which of the following best describes you?







How well does your partner meet your needs?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

In general, how satisfied are you with your relationship?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

How good is your relationship compared to others in the past?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

How often do you wish you hadn't gotten into this relationship?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

To what extent has your relationship met with your original expectations?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

How much do you love your partner?

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I often feel that my relationships are unfair or that I give more than I get in return.

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I fear that my needs will not get met in my relationships

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I often hold back from expressing my feelings to my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I hide my emotions from my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I need a lot of reassurance from my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I worry that I share too much personal information with my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

My partner does not really know me

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I keep secrets from my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel uncomfortable showing physical affection

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel uncomfortable showing appreciation to my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel uncomfortable spending time alone

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I often get into arguments with my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I have difficulty initiating contact with my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel controlled by my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel trapped by my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel restricted by my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I often get angry and aggressive with my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I often feel suspicious of my partner's intentions

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

I feel suffocated or trapped by my partner

  • 1 (Low)
  • 2
  • 3
  • 4
  • 5 (High)

Do you have a history of any mental health disorders? If so, are you currently seeking treatment?

Do you currently have an alcohol, substance abuse, gambling, or pornography problem?

Did one of you recently have an extra-marital affair (sexual or emotional)?

Have one or both of you been physical or emotional abusive towards one another? If so, did this result in hospitalization or a trip to an urgent care?

Would you like to share anything else with your provider through an upload?

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