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)