RELATIONSHIP CHECK-IN
1.
What is your age?
18-24
25-29
30s
40s
50s
60s
70+
2.
Please indicate your gender
Male
Female
Prefer Not to Answer
3.
Which of the following best describes your relationship status?
Married
Engaged
Seriously Dating
Living Together (not married)
The next series of questions is intended for married couples or couples in a committed relationship. Rate how you currently feel about your relationship in the following categories:
4.
Closeness / Connection
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
5.
Spiritual Beliefs / Faith
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
6.
Communication
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
7.
Finances / Money
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
8.
Roles & Expectations
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
9.
Conflict Resolution
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
10.
Commitment
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
11.
Intimacy & Affection
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
12.
Time Together
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
13.
Expressing Appreciation
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
14.
Forgiveness
7 - Excellent
6
5
4 - Okay
3
2
1 - Struggling
15.
All in all, how satisfied are you with your relationship? Are you . . .
Completely Satisfied
Very Satisfied
Somewhat Satisfied
Not Very Satisfied
Not at all Satisfied
16.
In what year were you born?
1999 - 2004
1984 - 1998
1965 - 1983
1946 - 1964
1925 - 1945
Current Progress,
0 of 16 answered
