Marital Assessment Survey

Your Full Name (required)

Your Email (required)

Phone (required)

1. When did you and your spouse first meet each other? (required)

2. What was the time frame that you and your spouse dated before marriage? (required)

3. How was the decision to live together or marry made? (required)

4. What was the relationship like before you married?

5. What did you find attractive about your mate before you married?

6. What year did you marry?

7. What frustrates you most about the communication between you and your spouse?

8. What would you describe are the strengths in your marriage?

9. What do you feel is the weakest area of your marriage?

10. What are your goals for your marriage?

11. How would you describe yourself as a listener?
a. As your spouse talks to you, do you listen just for the facts or do you try to sense how he or she is feeling?
YesNoSometimes

b. When your spouse talks, do you find it difficult to keep your mind on the subject at hand?
YesNoSometimes

c. Do certain topics or phrases your spouse says prejudice you from objectively listening to what is being said?
YesNoSometimes

d. When you are frustrated by what your spouse says, do you try to get the question straightened out immediately?
YesNoSometimes

e. If you feel it would take too much time and effort to understand something, do you go out of your way to avoid hearing about it?
YesNoSometimes

f. When you spouse talks to you, do you try to make him or her think you are paying attention to them when you are not?
YesNoSometimes

g. When your spouse is talking to you, are you easily distracted?
YesNoSometimes

12. On a scale of 1-10, describe your level of commitment to your relationship (1=Not at all, 10=Extremely).
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13. If you were to give a letter grade of A, B, C, D, or F, what grade would you give your spouse for their listening skills?
---ABCDF

14. Have you been married prior to the marriage with this spouse? if yes, please explain the reason for the divorce.

15. Please explain how you and your spouse handle conflict.

16. Please describe the most sensitive topic that is difficult for you to open with your spouse and why?

17. How are you coping with the challenges currently being experience in the marriage?

18. What role do you feel personally contributed to the problem(s) in your relationship and what have you done to resolve them?

19. Please respond to the items below that apply to your current situation:

Shoved, Pushed, Hit, or physically assaulted spouse. Describe details."

Currently separated. How long: Circumstances: Describe details

I or my spouse have/has threatened with separation. Describe details

I or my spouse have/has threatened divorce. Describe details

Do either of you or your spouse self-medicate with alcohol or drugs? If so how often and with what specific drugs or/and alcohol?