Couple's Questionnaire

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Background Information

How many years have you been married to your present spouse?

Did you live together prior to marriage? How long?

Were either of you previously married? If so, who and how many times? How many years between your previous marriage and this marriage?

Are you currently, or have you been in the past, engaged in any personal therapy? If yes, are there any professional diagnosed issues? How long have you been involved in therapy?

Are you currently, or have you been in the past, engaged in couples' therapy? If so, for how long? What are the main issues being addressed?

Are there any issues, problems or challenges that led you to decide to come to this intensive retreat?

In terms of your marriage, what are the relational goals that you wish to work towards at this time?

What initially attracted you to your partner?

What do you believe initially attracted your partner to you?

What do you find most fulfilling about your relationship?

What do you find least fulfilling about your relationship?

Do you feel disillusioned by this relationship? What happened? How did you attempt to resolve it?

When you experience conflict in your relationship, give a "snapshot" of how you both attempt to manage conflict.

When you experience strong emotions (positive or negative), how are they handled?

How emotionally safe do you feel expressing your innermost thoughts and feelings to your partner? To what degree are you safe for your partner to express inner thoughts and feelings? Please explain.

How does your mate attempt to care for your feelings and needs? Please explain. Do you feel cared for? Please explain.

How do you demonstrate care for your mate's feelings and needs? Does your mate feel cared for?

How do you ask for care and support when you need it?

In what ways have you contributed to your marital struggles?

If your relationship were a drama, movie, or book, what would it be titled? How would it end?

Has there, or is there any history of physical abuse, addiction or sexual abuse in your marriage? Explain.

How satisfied are you with your relationship with your spouse prior to attending this intensive?

I'm extremely dissatisfied

I'm not satisfied

I'm on the fence

I'm satisfied

I'm extremely satisfied

How committed are you to your spouse/marriage prior to this intensive?

I am pursuing divorce

I am leaning towards separation or divorce

I am not sure. I'll know after this intensive

I want to keep working on our marriage

Divorce is not an option

What are the current living arrangements with your spouse?

We are separated.

We are living in the same house, separate bedrooms.

We are living in the same house, same bedroom.

Other

What is the level of hope you have for your marriage's success if you attend this intensive?

I don't have hope ... I'm just doing this to say, "I've done all I could!"

I don't have a lot of hope.

I'm open to seeing what happens

I have a glimmer of hope

I'm extremely hopeful

Other

Please check any of the following boxes that are true of you:

I am a Christian.

I am a Christian, but I still have a lot of questions about my faith.

I believe in God, but align with beliefs other than Christianity.

Faith is important to me, but I am not sure what I believe.

Faith is not important in my life.

I attend church two or more times a month.

I talk about my faith and the Bible with others regularly.

I read my Bible outside of church.

I have someone (other than my spouse) that holds me accountable in my spiritual walk and life.

I believe that the Bible is God's Word and can be trusted as true.

I am a member of a local church.

I have been baptized.

I have someone that I call "My Pastor."

Any additional information you would like us to know:

Background Information

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