COUPLES RELATIONSHIP ASSESSMENT FORM



1. Clients names: __________________________________________ Date: _________

2. What relationship support experiences have you participated in?

(counseling, coaching, workshops, classes, etc.)

3. What was most helpful to you about that?

4. What was least helpful to you about that?

5. What areas of your relationship are working well?

6. What areas of your relationship are not working well?

7. What do you intend to accomplish through coaching?

8. Which of the following relationship and/or communication skills would you like to improve?

___ Balancing work/family/social/etc.

___ Learning Caring behaviors that feed the heart

___ Understanding/knowing your partner

___ Facing challenges

___ Sharing Interests & Fun

___ Keeping chemistry alive

___ Deepening emotional and physical intimacy

___ Being a conscious communicator

___ Being a conscious listener

___ Improving Negotiation/Conflict Resolution

___ Releasing hurtful reactions

___ Softening your approach

___ Using Soothing techniques for yourself/partner

___ Improving Calming strategies

___ Creating rituals of connection

___ Expressing differences effectively

___ Requesting vs. complaining

___ Releasing old patterns, stories, limiting beliefs, and programs

___ Using the Law of Attraction in your relationship

___ Creating your values, needs, wants, and requirements as individuals/as a couple

___ Creating a vision of your relationship together

___ Learning to use your relationship as a tool for personal and spiritual growth

___ Other(s) _______________________________________________________

9. What are the dreams you have for your relationship?

10. What dreams have you given up on?

11. How would you describe your source of strength?

12. How would you describe your spiritual path?

13. What do you value most about your life?

14. What do you value most about your partner?

15. What do you value most about your relationship?

16. What do you think stops you from having the relationship of your dreams?

17. What commitment are you ready to make toward accomplishing your goals and dreams?

18. What would you like to focus on first?

19. What would you like from me as your Coach?

20. What else would you like me to know?

21. What are you uncomfortable sharing/discussing with your partner and why?

Relationship Rating

Score your relationship on a scale of 1-10 with 1 being “poor” and 10 being “great.”

|Area of Relationship Concern |Current 1-10 Rating |What would make it a 10? |

| | | |

|Emotional Intimacy | | |

| | | |

|Relationship Priority & Commitment to Growth| | |

| | | |

|Chemistry/Sex/Intimacy/ Affection | | |

| | | |

|Fun/Shared Activities/Leisure | | |

| | | |

|Friendship | | |

| | | |

| | | |

|Communication / | | |

|Conflict Resolution | | |

| | | |

|Independence/ | | |

|Interdependence | | |

| | | |

| | | |

|Trust & Integrity | | |

| | | |

|Reliability | | |

| | | |

| | | |

|Supportiveness / Respect / Validation | | |

| | | |

| | | |

|Shared Goals/Vision/ Values | | |

| | | |

|Home Maintenance/ Housework | | |

| | | |

|Parenting as a Single Unit | | |

| | | |

| | | |

|Schedules | | |

| | | |

| | | |

|Extended Family | | |

| | | |

| | | |

|Finances: Bill Paying/ Budgeting | | |

| | | |

|Finances: Saving/ Investing | | |

| | | |

| | | |

|Finances: Equality | | |

| | | |

|Finances: Shared Values, Habits and Goals | | |

| | | |

|Vacations | | |

| | | |

|Your job | | |

| | | |

|Partner’s job | | |

| | | |

|Your Health & Well-Being | | |

| | | |

|Partner’s Health & Well-Being | | |

| | | |

|Religion / Spirituality | | |

| | | |

|Politics | | |

| | | |

|Community Involvement | | |

| | | |

|Other | | |

What are your insights as a result of this assessment? __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

What are your immediate and long term goals, as a result of these insights?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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