Couples Screening Form – Dontrell Brailsford"*" indicates required fieldsName* First Last Today's Date* Check the items that apply.MOODS: (ex. Irritability, depression, etc.) My moods are a problem to our relationship. My partner’s moods are a problem to our relationship.Comments:ALCOHOL and SUBSTANCE USE: My use of alcohol is excessive. My partner’s use of alcohol is excessive. My use of prescription or illegal drugs is a problem. My partner’s use of prescription or illegal drugs is a problem.Does alcohol intake or any other substance interfere with your relationship? Yes NoComments:AGGRESSION: My temper adversely affects our relationship. I have been verbally abusive to my partner. I have been physically abusive to my partner. My partner’s temper adversely affects our relationship. My partner has been verbally abusive to me. My partner has been physically abusive to me. Our fights and arguments are very destructive to our relationship.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 COMMITMENTDirections: 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% = ExtremelyI 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.*
