Name:______________________________________Date:___________________
Couple Screening Form
Directions: D Check the items that apply
MOODS: (ex. irritability, depression etc.)
____My moods are a problem to the relationship. how?:
____My partner's moods are a problem to the relationship. how?:
ALCOHOL and SUBSTANCE USE
____My use of alcohol is excessive
____My use of prescription or illegal drugs is a problem
____My partner's uses alcohol excessively
____My partner's use of prescription or illegal drugs is a problem
AGGRESSION
____My temper adversely affects our relationship
____I have been verbally abusive to my partner
____I have been physically abusive to my partner
____My partner's temper adversely affects our relationship
____My partner has been verbally abusive to me
____My partner has been physically abusive to me
____Our fights and arguments are very destructive to our relationship.
AFFAIRS
____I have had an affair during our relationship (or an inappropriate outside relationship).
____I am currently having an affair (or an inappropriate outside relationship).
____My partner has had an affair during our relationship (or an inappropriate outside relationship).
____My partner is currently having an affair (or an inappropriate outside relationship).
SATISFACTION AND COMMITMENT
______% I am committed to staying in our relationship.
______% Overall how satisfied are you now with your relationship?
© 2003 Douglas Tilley, LCSW-C
Directions:
In percentage terms, how strongly do you agree with the statements below.
Use this scale to answer the questions below.
0 25% 50% 75% 100%
Not at all Slightly Moderately Very Extremely
______% I feel disorganized by all this negative emotion.
______% I can't think straight when my partner gets so negative.
______% Talking things over with my partner only seems to make them worse.
______% I have little confidence that we can discuss a significant problem without fighting.
______% I am basically unhappy with my relationship.
______% I have often felt like leaving my partner.
______% I often don't feel close to my partner.
______% I'm not satisfied with our sex life.
______% I feel lonely in our relationship.
______% I feel we are disconnected.
______% My partner and I live pretty separate lives.
______% I confide in a special person outside of our relationship. Who?
______% There are specific events in our relationship which I am having trouble getting over.
What?
______% In spite of all our problems, I believe that my partner really cares about me.
© 2003 Douglas Tilley, LCSW-C
