Only with insight can you begin to address your concerns. We hope you will find the use of the questionnaires helpful.
If you or your partner are self employed we would also ask you to help us by completing an online survey with Hull University on the affects of self employment on couple satisfaction. All answers are confidential. Please go to www.surveymonkey.com/K7WWK52 (if the link does not work first time please type it in manually.
Here is a short questionnaire with just a few of the kind of issues that put pressure on a relationship. Why not print out a couple of copies and check out your own responses on one. Now do the same thing again but this time answer as if you were your partner - do this as truthfully as possible.
Now ask yourself:
What beliefs do I hold about how people (self and partner) 'ought' or 'should' behave.
Where did I get these ideas?
Would life collapse if I were to abandon or moderate some of these oughts and shoulds?
Would life actually be better for me and those around me if I relaxed some of these beliefs?
Now check out your responses again using a different coloured pen and in the light of these relaxed beliefs. Now look at those sections where you have not been able to alter your assessment. These are the important concerns you need to address with your partner if you want to improve your situation.
Show the questionnaire to your partner and explain that you are trying to understand how your own concrete beliefs may be having damaging consequences on your relationship, and you intend to try to be more relaxed about them, but that you feel strongly that you need them to help the relationship by being honest with themselves and addressing the remaining issues.
Only when you have both seen that you can alter your concrete beliefs do you need to address those remaining issues by reasoned discussion and a willingness to meet each other half way
There may be stubborn points that you find difficult to resolve together. A good counselor, such as Absolute Discretion Counselling Therapy will have a wide experience of helping with relationship problems, particularly those not amenable to reasoned discussion.
Do you find yourself wondering: Why do I feel like this? What do I need? What is going on in my life?
Whether you think you may use counselling or not you may find it helpful to honestly identify what is happening in YOUR life. Why not complete the questionnaires below? We are sure you will find completing the form helpful even if you never use counselling.
People, and the situations they find themselves in, are often very complex, so you need to understand as much of the context as possible in order to help find a solution. The form below is designed to help to learn about you, to admit things about yourself and those around you and better to understand your situation.
If you decide to begin counselling would be useful for your counsellor to see a copy.
While one questionnaire need to be completed, with two people there comes two perspectives - each adult should complete the relevant sections. This can be done by
REVISITING THE SITE OR BY PRINTING OFF ANOTHER FORM.
When completing these sections it is better not to seek the views of the other person as you go along.
The questionnaire is complex because people and situations are many faceted and complex.
Skip Section One Unless and Until You Decide to Come For Counselling
Section 1
Couples Questionnaire - one adult only completes this part of the form for a couple .
(only complete this section when you are ready to start counselling)
Today's Date. Full Name of person completing this form. . Current Age. . Place of Birth.
. . .
Home Phone. . . leave message? Work phone. leave messages? Mobile Phone . leave messages?.
Y/N Y/N Y/N
The other person if a couple
Full name of person NOT completing this form. . . . Current Age Place of Birth.
Home Phone. . . leave message? Work phone. leave messages? Mobile Phone leave messages?.
Y/N Y/N Y/N
Primary address of couple - Address . . Town/City. . Post Code.
how long since married living apart Y/N.
Who can we call in the event of an emergency? Name Phone
Name of your GP Phone
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Section 2
Questionnaire - General Questions
Yourself (Ist person) circle all that apply
Have you ever been?
Previously cohabiting Y/N separated Y/N married before? Y/N
how many times?
Has Partner Ever been?
married before Y/N Previously cohabiting Y/N
How many times?
Other Matters
yourself. your spouse / partner.
race / ethnicity. Race / ethnicity
religion / denomination.
. .
date of birth.
. .
sexual orientation.
. .
names & ages of children conceived with current spouse/ partner.
names & ages of children conceived with previous spouse(s)/partner(s).
Education and Work Status
.
highest level school completed.
.
current occupation/ education/benefit status.
hours worked each week.
.
how long worked at present occupation?.
.
second jobs.
.
how long at this second job?.
.
hours worked each week at second job.
. .
any problems at work / school?.
. .
unemployed?.
. .
why unemployed at present?.
. .
how long unemployed?.
. .
Medical and health
yourself. your spouse / partner.
last physical exam date.
. .
results of exam?.
. .
current physical problems.
. .
any head injuries / seizures? If so when?.
. .
any major illness past or present?.
what & when?.
. .
any operations?.
what & when?. . .
any prior hospitalizations?.
for what & when?.
. .
any family history of alcoholism?. Y / N who?
Any other person
any family history of depression?. Y / N who?.
Any other person
any family history of mental illness?. Y / N who?.
Any other person
List your personal strengths.
. .
List personal weaknesses.
. .
list personal hobbies.
. .
Please list everyone else who lives in the household at least two days per week - please list from oldest to youngest.
Full name. . . Date of Birth Age School / occupation. .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
Section 3
Counselling history
Is anyone presently getting counselling? Yes / No Who?_________________ why?_______________________.
for how long?__________ With whom/organisation?______
Medical
Is anyone currently under a doctor's care for physical problems? Yes/No who? ___________________.
For what? ______________________________With whom? _______.
Involvement with the Police or the law.
Has anyone ever been arrested and/or committed a crime? Yes / No
who?______________________________.
When _________________________ For what?____________________________________________________.
Outcome __________________________________________________________________________.
Continue for other events/details
Section 4
Medication you have used, and was it helpful?
Current Non-Psychiatric Medications.
person taking.
Type of medicine.
medicine dosage.
purpose.
how long on this medicine?.
. . . . .continue with other non-psychiatric medications
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
Current Psychiatric medications.
person taking.
Type of medicine.
Medicine dosage.
purpose.
how long on this medicine?.
. . . . .continue with other psychiatric medications
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
Previous Psychiatric Medications.
(Please list each drug in date of use order. Begin with the first medication used for an emotional problem.)
person taking.
medicine.
Medicine dosage.
purpose.
how long on this medicine?.
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
. . . . .
Section 5
Summary of previous counselling .
Please give details
.............
. . . . .
.....
reasons for stopping treatment.
what type of therapy?
was it helpful?
did you have any negative responses?
Or reactions?.
Section 6
Reason(s) for seeking counselling (Each partner in the couple may want to complete their own section)
Partner 1
Name________________________________________________
Why are you coming to counseling at this time?____________________________________________________.
Are you being pressured to come to counseling? By whom and why?____________________________________.
Have you been referred? Yes / No By whom?_____________________________________________________.
What problems are you wanting to address in counseling?:____________________________________________.
How long have these problems existed? __________________________________________________________.
What makes these problems worse? ______________________________________________________________.
What makes these problems improve? ____________________________________________________________.
Overall, how motivated are you to change these problems? . Very motivated-----------------------------not motivated .
10 - 9 - 8 - 7 - 6 - 5 - 4 - 3 - 2 - 1 .
Circle one
What do you expect from therapy?_______________________________________________________________.
Name ___________________Reasons for seeking counseling.
(each adult complete this form).
Partner 2
Name:___________________________________________
Why are you coming to counseling at this time?____________________________________________________.
Are you being pressured to come to counseling? By whom and why?____________________________________.
Have you been referred? Yes / No by whom?_____________________________________________________.
What problems are you wanting to address in counseling?:____________________________________________.
How long have these problems existed? __________________________________________________________.
What makes these problems worse? ______________________________________________________________.
What makes these problems improve? ____________________________________________________________.
Overall, how motivated are you to change these problems? . Very motivated-----------------------------not motivated .
10 - 9 - 8 - 7 - 6 - 5 - 4 - 3 - 2 - 1 .
Circle one
What do you expect from therapy?_______________________________________________________________.
Section 7
Problems, concerns and symptoms
Please check any of the following which may apply to anyone in the household - you should include all issues even if not obviously thought to be relating to the reasons you are considering counselling.
problem who has the problem?
agitation (physical symptoms) inability to make/keep friends
alcohol use inability to relax legal matters
angry outbursts loneliness
anorexia or bulimia (past /present) loss of interest in things
anxiety loss of sexual interest or desire
bad dreams marriage problems
bereavement memory problems
boredom nervousness
can't get motivated to anything not interested in things usually
enjoyed
career choices obsessive behaviour
chat room on line use on-line pornography
controlling behaviour over-eating
crying easily over-use of computers
depression parent - child conflict
difficulty concentrating paranoia
difficult getting to or staying asleep poor appetite
difficulty getting up in the morning poor communication skills
difficulty making decisions poor or decreased ambition
difficulty parenting pornography use
divorce preoccupation with death
drug use self-obsession/selfishness
easily annoyed or irritated school problems
existing/past legal problems sexual problems
emailing(emotional/sexual content) self-confidence
sex-site use and sex-dating
energy problems self-harm/mutilation
extreme fear of places or events shyness
faintness or dizziness stuttering
fatigue suicidal attempts
feeling controlled suicidal thoughts
feeling fearful texting addiction
feeling inferior to others thoughts found hard to get rid of
feeling tense or nervous trouble remembering things
financial problems uncontrollable outbursts of temper
friendship problems unhappiness
gambling violent behavior
gaming on line violent thoughts
guilt web use
internet use work problems
impulsiveness worrying about things
Section 8
Please check any of the following which may apply to anyone in the household. Please check issues even if they do not relate to the primary reasons you are considering counselling..
Substance use Checklist - Name ______________________.
(Each Adult completes separate form revisit the site or download a copy).
Problem Who has a problem?
I consume alcohol…..
. never.
. 1time/ month.
. 2-4 times / month.
. 2-4 times / week.
. daily.
The following apply to me (check all that apply).
. I rarely or never drink - not even socially.
. I'm an occasional/ social drinker.
. I'm not sure if I have a problem .
. I probably have a problem.
. I have a problem, and I want to stop.
. I have a problem, but I don't want to stop.
When I drink, I usually.
drink…..
. none.
. 1-2 drinks or beers.
. 2-3 drinks or beers.
. 3-4 drinks or beers.
. 5+ drinks or beers.
I get drunk…..
. never.
. 1x/ month.
. 1-4x/month.
. 2-4x / week.
. daily.
I've been drinking like this.
for the....
. last month.
. 2-6 months.
. 6-12 months.
. more than a year.
. more than 3 years.
My drinking has resulted.
in one or more of the.
following....
. passing out.
. sleep disturbances.
. can't stop once I start.
. blackouts.
. relationship problems .
. binges.
. work/school problems .
. seizures.
. Assaults &/or arrests.
. physical withdrawal.
. legal problems.
. medical complications.
I've tried to control my drinking with.....
. Nothing!.
. I stopped on my own.
. I've attended AA / other 12-step program a few times.
. I've attended AA / other 12-step program a regularly.
. I attended day or outpatient treatment.
. I attended inpatient / residential treatment.
.
I attended a community-based program (e.g., church.
program, etc.).
I was forced to attend treatment of some kind.
Other Substances I currently use / I once used / I only ever tried…. .
No substance use ever.
tried only once/twice.
used regularly.
age started.
age stopped.
Type of substance
pot. . . . .
sedative. . . . .
stimulant. . . . .
cocaine. . . . .
meth. . . . .
inhalants. . . . .
Heroin/ opium. . . . .
prescription drugs. . . . .
LSD, mushrooms. . . . .
other. . . . .
Gambling
The following apply to me (check all that apply).
I gamble at casinos/ bookies/internet/on the street/on machines/at cards/horses/dogs/with my career
I don't gamble.
I gamble occasionally.
I like to gamble.
Gambling has caused me problems.
I have gambled until all my money was gone.
I have gambled more than I planned to.
I like to gamble to escape worry or trouble.
I have borrowed money in order to gamble.
At times I've felt remorse after gambling.
I've lost time from work or school due to gambling.
We hope that by completing this questionnaire you have found a better understanding of your present position.
This is just the starting point from which to work towards a happier life. People can change if they want to enough, and if they find the right support. The greatest obstacles to change are lack of will, and the
reluctance of others around you to allow change because they are afraid of having to change themselves.
The support of a qualified counsellor can help you to make the changes you want.
If you or your partner are self employed we would also ask you to help us by completing an online survey with Hull University on the affects of self employment on couple satisfaction. All answers are confidential. Please go to www.surveymonkey.com/K7WWK52 (if the link does not work first time please type it in manually