Couples Screening Form - Wellness Counseling Center

Name*

First Last

Date*

Check the items that apply.

MOODS: (ex. Irritability, depression, etc.)

Comments:

ALCOHOL and SUBSTANCE USE:

Does alcohol intake interfere with your relationship?

Comments:

AGGRESSION:

Comments:

AFFAIRS:

I have had an affair during our relationship (or inappropriate outside relationship).
I am currently having an affair (or inappropriate outside relationship).
My partner has had an affair during our relationship (or inappropriate outside relationship).
My partner is currently having an affair (or inappropriate outside relationship).

Comments:

SATISFACTION AND COMMITMENT

Directions: In percentage terms, how strongly do you agree with the statements below.

Use this scale to answer the questions below.

0 = Not at all | 25% = Slightly | 50% = Moderately | 75% = Very | 100% = Extremely

I am committed to staying in our relationship.*

Overall, I am satisfied with our relationship.*

I feel disorganized by all this negative emotion.*

I can't think straight when my partner gets so negative.*

Talking things over with my partner only seems to make them worse.*

I have little confidence that we can discuss a significant problem without fighting.*

I am basically unhappy with my relationship.*

I have often felt like leaving my partner.*

I often don't feel close to my partner.*

I'm not satisfied with our sex life.*

I feel lonely in our relationship.*

I feel we are disconnected.*

My partner and I live pretty separate lives.*

I confide in a special person outside of our relationship. Who?*

There are specific events in our relationship which I am having trouble getting over.*

Comments:

In spite of all of our problems, I believe that my partner really cares about me.*