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Relationship Health Assessment

Please, answer the following questions to the best of your ability. It may take you about 15 minutes to complete this questionnaire.

You may set up some quiet reflection time for yourself and fill this form out as honestly and whole-heartedly as possible. This is your time and investment in your best self. This information will help your coach to assist you better with your goals and interests.

Click the Button Below to Start

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Question 1 of 17

Tell me a little bit about yourself and your relationship and why you decided to sign up for Relationship Breakthrough audit.

Question 2 of 17

Are you currently in a relationship?

A

Yes

B

No

Question 3 of 17

What are the biggest challenges you've been facing in your relationship/s?

Question 4 of 17

What have you tried to help yourself so far in regards to this  situation/issue? 

Question 5 of 17

Are there any other challenges in your life?

(Select all that apply)
A

Assertiveness and People Pleasing

B

Difficulty Saying NO and Setting Boundaries

C

Anxiety

D

Depression

E

History of Trauma

F

Strained Family Relationships

G

Work Issues

H

Chronic Pain

I

High Levels of Stress

J

Other...

Question 6 of 17

Are you currently under the care of a psychiatrist or licensed psychotherapist?

A

Yes

B

No

Question 7 of 17

Great, thanks! Now, let's assess the way conflict is managed in your relationship.

 

Are you satisfied with the way you deal with conflict and issues in your relationship?

(Select all that apply)
A

Mostly satisfied

B

Not satisfied at all

C

Somewhat satisfied

D

I wish I can handle it better

E

I/We definitively need improvement in this area

Question 8 of 17

Do your conflict discussions/arguments look like this?

(Select all that apply)
A

Our arguments seem to come out of nowhere – sometimes over a cup of coffee.

B

Our arguments often begin or end with blaming, criticism, or statements that one of us is flawed in character or personality.

C

During an argument, my partner tends to criticize my personality or attack my character.

D

We just keep hurting each other whenever we discuss our core issues.

E

My partner and I are very quick to explode when a conflict comes up.

F

My partner doesn’t seem to deal with issues in our relationship responsibly and maturely, and we just can’t seem to have effective conversations to address them.

G

I find my partner’s negativity quite unnerving and upsetting.

H

I avoid disagreements with my partner by changing the subject or pretending it’s “nothing important”.

I

During an argument, my partner and I tend to keep going in circles and in the end, I feel disappointed and discouraged.

J

My partner acts as if I’m totally wrong and he/she is totally right.

K

I don’t feel heard and validated by my partner.

L

My partner and I end up being more disconnected after an argument or fight.

Question 9 of 17

Now, let's talk about the other aspects of your relationship and connection with your partner. 

(Select all that apply)
A

We trust each other

B

We respect each other

C

We support each other's interests and efforts

D

We are honest and open with each other

E

We are able to maintain our individual identity in our relationship

F

We talk to each other about our feelings, hopes, fears, and dreams.

G

We often express care and affection with each other.

H

There is equality and fairness in our relationship.

Question 10 of 17

Anything you wish to add about your relationship?

Question 11 of 17

We are almost done here! Just a couple of more questions.

 

What are your personal (and mutual) relationship goals? 

Question 12 of 17

If I can help YOU accomplish your life and relationship GOAL/S or create amazing RESULTS, what would that look like? 

Question 13 of 17

What do you think could be standing in your way of achieving your relationship goals? What are your biggest barriers?

Question 14 of 17

What would make you feel the most empowered and fulfilled in your life right now? 

Question 15 of 17

Do you believe you are TRULY ready to make positive changes in your life and relationships even if you don't know how to get there  at this point?

A

Not sure

B

Somewhat ready

C

I think I'm ready

D

Yes, I'm definitively ready!

Question 16 of 17

Making healthy and meaningful change in life is not easy but could be the best choice and  investment in a long run. Are you wiling to do the work it takes to have your desires manifested? Are you willing to follow through commitments? 

Question 17 of 17

By placing my initials below, I agree that this is not psychotherapy or crisis hotline, that I will not be given a mental health diagnosis, and that this consult is for initial exploration of my  relationship issues, goals, needs and possible treatment/service options.

Confirm and Submit