Therapist's Guide to Clinical Intervention - Sigmund Freud

RELATIONSHIP QUESTIONNAIRE
This questionnaire is intended to estimate the current satisfaction with your relationship.
Circle the number between 1 (completely satisfied) to 10 (completely unsatisfied) beside each
issue. Try to focus on the present and not the past.
1. List the things that your partner does that please you:
2. What would you like your partner to do more often?
3. What would your partner like you to do more often?
4. How do you contribute to difficulties in the relationship?
5. What are you prepared to do differently in the relationship?
6. Is there a problem of alcohol/substance abuse?
7. Do you often try to anticipate your partners wishes so that you can please them?
8. What are your goals or what do you hope to accomplish?
General Relationship
Personal Independence
Spouse Independence
Couples Time Alone
Social Activities
Occupational or
Academic Progress
Sexual Interactions
Communication
Financial Issues
Household/Yard
Responsibility
Parenting
Daily Social Interaction
Trust in Each Other
Decision Making
Resolving Conflicts
Problem Solving
Support of One Another
completely
satisfied
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
2 3 4 5 6 7
HEALTHY ADULT RELATIONSHIPS: BEING A COUPLE
completely
unsatisfied
8 9 10
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
89 10
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
8 9 1 0
Because people change over time so do their relationships. When two people initially get
together there is the excitement and passion of a new relationship. Then they make a commitment
to one another. During this time of commitment each person has an expectation
that things will feel wonderful forever. This period of relationship development lasts for 1 to
2 years. During this time they begin to notice that there are differences in beliefs and how
each would like to handle various situations. However, they continue to put their best foot
forward, feeling close and enjoying one another.
As this period of discovery continues there are disagreements and differences of opinion,
but they don't talk about it. They tend to hold back fearing an increase in disagreements.
They are struggling to find a way to go beyond being two people in a relationship to being
two people who are sharing their lives together and building a future.
396 3. Skill-Building Resources for Increasing Social Competency