Integration Course

Download:  MSWORD


Couple’s Relationship Survey

(Dr. Brian Campbell, Copyright, 2015)


Names:  _______________________________________________________     Date: ____________________

This document is designed to be used as an initial interview tool with couples.

1.          Communication:  Frequent fighting/disagreements  Can’t resolve problems Stopped talking      Name calling   Silent treatment         Yelling/shouting   “Put-downs”   Sarcasm  Verbal abuse     Discounting   Threatening   Nagging  Not listening  Frequent interrupting   Focuses on the past            Constantly worries about future   Frequent accusations  Jealousy   Anger problems   Misunderstanding   Blaming/criticizing    Problems forgiving hurts  Self-centered   OTHER:____________________________


2.       SEXUALITY:  Frequency disagreements  Sexual frustration No romance   Going through the motions        Lack of variety/bored   Avoidance  Rejection   Low sex drive  Physical problems   Too exhausted/tired                 No interest     Erection problems  Orgasm problems  Low testosterone Female hormone problems           Painful  Guilt feelings   Extramarital affairs      Flirting with opposite sex   Pornography   Internet/social media affairs  OTHER: __________________________________________________________________________


3.       FINANCIAL:  Major disagreements  Frequent arguments  Overspending   Too tight/frugal  Spending disagreements    No savings  Poor investments  Major loss of money  Unemployment  Business failure Bankruptcy  Excessive credit card debt  Medical bills  Student loans      OTHER:  ______________________________________________________________________________________ 


4.       PARENTING:  Major disagreements   Too lenient/spoiled  Too strict/harsh    Disagreement on spanking    Major child misbehavior  Listens to one parent but not the other  Allows whining  Allows talking back       Enmeshment   Overprotective   Over controlling  Under involvement    Ex-spouse interference  In-law interference  Underachievement at school   Poor grades  Behavior problems at school   Behavior problems at home  Problems making friends  Rejection by other children  Fighting with siblings Anger problems      Temper tantrums Hitting others   Disobedience   Truancy    Drug use  Alcohol use  Arrests             Immaturity Social skills problems  OTHER: ____________________________________________________


5.       ABUSE:  Physical abuse Verbal abuse  Emotional abuse  Child abuse  Sexual abuse                           
OTHER:  _____________________________________________________________________________________


6.       ADDICTIONS:  DRUGS/ALCOHOL/OTHER:  Substance abuse (Illicit) Drug abuse (Prescribed)    Alcohol  abuse   Gambling    Sexual Addiction  Overeating   OTHER:   _______________________________________


7.       RELIGIOUS DIFFERENCES:  Different upbringings  Theological disagreements  Disagreement on which church to attend   Frequency of attendance  Over-commitment    Under-commitment   Denomination


8.       PHYSICAL:  Physical limitations/disabilities   Pain problems    Over-weight  Under-weight     Allergies  Immune system disorders  OTHER:  _______________________________________________________________


9.       IN-LAW INTERFERENCE:    Parenting  Living arrangements  Vacations   Spending/finances             
OTHER:  _______________________________________________________________________________________

(Permission is granted for use in counseling)