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RELATIONSHIP HEALTH QUESTIONNAIRE

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This questionnaire takes about 15 minutes.

Start

Question 1 of 14

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

Question 2 of 14

Are you currently in a relationship?

A

Yes

B

No

Question 3 of 14

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

Question 4 of 14

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

Question 5 of 14

What are some of your relationship strengths? 

Question 6 of 14

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 7 of 14

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

A

Yes

B

No

Question 8 of 14

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 9 of 14

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 10 of 14

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 11 of 14

Anything you wish to add about your relationship?

Question 12 of 14

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

 

What are your personal (and mutual) relationship goals? 

Question 13 of 14

If everything is just the way you want it, what would your relationship look like 6 months from now?  

Question 14 of 14

What do you think could be standing in your way of those dreams? What are your biggest barriers?

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