Relationship Health Questionaire
Where are you on the journey of loving well?
Name
Email
Therapist Name
Therapist Name
Steven
Margo
Stefanie
I don't have a therapist
Gender
Male
Female
Age
15-25
25-35
35-50
50-65
65+
When I listen to my partner my own thoughts and feelings get in the way.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I explode my feelings outward or constrict and don’t talk.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I focus on trying to get my partner to see what s/he did wrong.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am able to express myself openly and calmly.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I focus on my contribution to our disconnection.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I take on all the blame and feel terrible.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I insist on getting my needs met no matter what.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am able to listen to my partner openly and non-defensively.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I can acknowledge my partner’s contribution and my own with compassionate understanding.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I respect and support my partner’s desires as much as my own.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I see our differences as valuable and additive.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I believe we should see eye to eye on all issues.
Strongly Agree
Agree
Slightly Agree
Slightle Disagree
Disagree
Strongly Disagree
I feel hopeless about the future whenever we argue.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I believe we are just wrong for each other.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am open to my partner’s attempts to reconnect.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I feel confident that we will repair our ruptures and feel close again.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I know our conflicts are opportunities to learn something.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I initiate repair attempts and can tolerate when my partner is not ready.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I complain about my partner’s behavior to try to get them to change.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am unable to respond when my partner tries to reconnect.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I wait for my partner to make repair attempts and do not try first.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I ask for behavior changes I want clearly and gently.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am able to tolerate when my partner says no to doing what I ask.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I get defensive when my partner asks me to change my behavior.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I listen to my partner’s requests and am willing to stretch into new behaviors.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I tell my partner about all of their flaws and behaviors I don’t like.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I notice and mention what I appreciate about my partner and celebrate our successes.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I never see or mention any flaws in my partner.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I talk about my negative reactions responsibly and also note what I appreciate.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I often feel my partner is against me and is trying to win.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I see us as on the same team to work through our challenges.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
If my partner would just change everything would be fine.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I see us as in this together, both contributing to the problems and solutions.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I see my partner as my enemy and need to protect myself.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am sure that the way I see things is the only right way.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I see my partner as safe and I am vulnerable with them.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I check out the accuracy of my interpretations of my partner’s behavior.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I am curious and open to understanding myself and my partner in new ways.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
My beliefs about my partner’s behavior bring me pain.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I do not expect to have to change to be with my partner.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I have an image of some new ways I want to be in our relationship.
Strongly Agree
Agree
Slightly Agree
Slightly Agree
Agree
Strongly Disagree
I want to behave differently as a result of my deeper understanding of us.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I follow through on my commitments to change behaviors.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
When I don’t follow through I avoid talking about it.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
When my partner doesn’t follow through I get discouraged and criticize them.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
Nothing is changing.We are stuck.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disgree
When my partner doesn’t follow through I get curious and open a dialogue.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree
I know we are on a journey of change and I notice the changes and progressions we are both making.
Strongly Agree
Agree
Slightly Agree
Slightly Disagree
Disagree
Strongly Disagree