Integral Business Coach 4505 44th Ave. SW, Seattle WA 98116 (425) 466-4842
MARITAL HISTORY QUESTIONNAIRE
Name: ______Date of Birth: ______
CHILDREN:
NameDate of BirthCurrently lives with:
Mother Father Both
______
______
______
______
CURRENT MARITAL CIRCUMSTANCES
Years Married ______Date of marriage ______
Reason you married ______
Currently separated? Yes/NoDate of separation ______
Filed for divorce?Yes/NoDate of filing ______
Who filed? ______Attorneys engaged? Yes/No
Wife’s attorney ______Husband’s attorney ______
Did you expect this separation?Did you want this separation/divorce?
___ Yes, for a long time___ Not at all
___ Yes, but only recently___ Have mixed feelings
___ Unexpected___ Want it very much
___ No, but am resigned to it
___ Feel it is for the best
If previously married, list the date(s) of previous marriages and divorces:
______
Factors contributing to the decision to separation/divorce (please check all that apply):
Recently had difficulty communicating______
Always had difficulty communicating ______
Differences in interests______
Differences in education level______
Differences in ethnic or racial background______
Differences in expectations about marriage______
Differences in expectations about family life______
Changes in lifestyle, values______
Lack love for one another ______
Verbal abuse______
Bored______
Sexual difficulties______
In love with another person______
Financial problems______
Unfaithful, infidelity______
Abuse or neglect of children______
Job or school commitment______
Suspiciousness, jealousy______
Neglect of home______
Trouble with in-law relationships______
Drinking______
Drug use______
Physical abuse______
Depression______
Sexual Abuse______
Other (explain) ______
Major life events and/or changes occurring within the last twelve months (check all that apply):
Started school or training program______
Graduated from school or training program______
Entered job market______
Changed job______
Lost job______
Moved residence______
Financial troubles______
Increase in financial responsibilities______
Legal problems______
Arrested and/or jailed______
Separation or divorce of friend or relative______
Health problems (self, spouse, children)______
Drinking or drug problems______
Began treatment for drinking or drug problems______
Began psychotherapy______
Began new medications______
Significant weight gain or loss______
Nanny, au pair or aging parent joined the household______
Nanny, au pair or aging parent left the household______
Death of a household pet______
Pregnancy______
Miscarriage______
Abortion______
Fertility problems______
Changes in childcare______
Children had trouble in school______
Onset of menopause______
Mid-life crisis______
Victim of a crime______
Auto accident______
Undertaken major new expenses______
Natural disaster______
Other (explain) ______
LEVEL OF CONFLICT
On a scale of one to ten, rate the level of conflict and anger during times/episodes of conflict in your marriage prior to the decision to divorce. One being low and ten being high.
Level of conflict in marriage1 2 3 4 5 6 7 8 9 10
Level of your anger1 2 3 4 5 6 7 8 9 10
Level of other’s anger1 2 3 4 5 6 7 8 9 10
Rate your level of anger now:
Level of conflict 1 2 3 4 5 6 7 8 9 10
Level of your anger1 2 3 4 5 6 7 8 9 10
Level of other’s anger1 2 3 4 5 6 7 8 9 10
At this time, regarding major change in our family:
I worry I will ______
______
I am concerned my children will ______
______
It’s important to me that the separation/divorce process ______
______
I think my spouse will ______
______
With regard to the future:
I worry I will ______
______
I am concerned my children will ______
______
It’s important to me that ______
______
I think my spouse will ______
______
CURRENT SOURCES OF EMOTIONAL SUPPORT (please check all that apply):
Friends_____
Family_____
Neighbors_____
Co-workers_____
Religion or spiritual practice_____
Therapist/counselor_____
Lawyer_____
Other: ______
OCCUPATION
What is your occupation?______
Are you currently employed?Yes/No
If yes, where are you employed? ______
How long have you held your current position?______
How satisfied are you with your current job/work situation?
___ Very satisfied___ Moderately satisfied
___ Moderately unhappy___ Extremely unhappy
PERSONAL HISTORY
Have you ever had any physical or mental illness, significant health problems or serious accidents that affect you for an extended period of time? If so, please list:
______
Your health in early childhood was generally:
___ Good___ Fair___ Poor
At present, your health is generally:
___ Good___ Fair___ Poor
How long ago was your last physical?______
Are you concerned about your own drug/alcohol use or that of your partner? Yes/no
If yes, please explain: ______
______
List all drugs/medications you are taking (including aspirin, vitamins, sleeping pills, etc.):
______
Are you currently in couple’s, family or individual counseling?Yes/no
If yes, what type of counseling is it?______
For how long?______
With whom?______
Do you have any concerns about your physical or emotional safety in your primary/intimate/spousal relationship? Yes/no
Has your spouse or intimate partner ever hurt you, your child, or a pet; or threatened to destroy something important to you? Yes/no
Has he/she ever (please check all that apply):
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Integral Business Coach 4505 44th Ave. SW, Seattle WA 98116 (425) 466-4842
___ Hit you
___ Smacked you
___ Bit you
___ Verbally degraded you
___ Pushed you
___ Kicked you
___ Chocked you
___ Called you names/put you down
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Integral Business Coach 4505 44th Ave. SW, Seattle WA 98116 (425) 466-4842
___ Forced you to have sex or perform sexual acts you didn’t want to do?
___ Threatened to use a weapon against you
___ Prevented you from leaving the house, seeing friends, getting a job or finishing school
___ Been excessively jealous, accused you of having affairs, or repeatedly checked up on you
Anything else you would like to mention or would like me to know?
______
INCOME
What current monthly income is available for you to live on? ______
Describe changes, if any, in your income since your separation: ______
______
COLLABORATIVE DIVORCE PROCESS
How did you hear about Collaborative Divorce? ______
______
What do you hope to accomplish by choosing Collaborative Divorce? ______
______
What do you consider to be the main issues? ______
______
What are your hopes for the future? ______
______
Beyond the information you have listed here, what else do you feel is important for us to know about you and your current situation:
______
Thank you for taking the time to fill out this questionnaire
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