EmailMe Form - GOALS Survey

Your Name *

Your Partner's Name *

(1) Working on your marriage with an outsider is not for everyone. What reservations do you have, if any? *

(2) Which is greater, your desire to get closer with your partner or keep your distance?

Keep my distance

Get closer

Not sure

Other

(3) How do you define a "close relationship"? *

(4a) GOALS: What do you want your relationship to look like going forward? List 3-5 desired outcomes. Define your goals in terms of what you want, not what you don't want. *

(4b) For each goal listed above, name a measurable baby step that could be made in the next two weeks that would indicate the relationship is moving toward that desired goal. *

(5a) Click each statement that is True: *

(a) There is physical abuse in this relationship.

(b) There is a physical or emotional affair going on, yet the unfaithful partner is not willing to break it off.

(c) There are addiction issues (e.g., alcohol, drugs, pornography, gambling), yet the addicted person has not taken steps to overcome them.

(d) There are mental health or trauma-related issues affecting our relationship that are not being treated.

None are Applicable

(5b) Briefly explain if you clicked a box above in (5a), or enter N/A (not applicable). *

(6) How committed are you to engage in the exercises assigned between sessions designed to achieve your relationship goals? *

(7) What percentage % do you think your partner is to blame for the problems you've been experiencing as a couple? *

(8) How open are you to pinpoint the behavior you engage in that is hurting the marriage and make changes to improve the relationship? *

(9) How connected do you currently feel toward your partner? *

I feel very connected.

I feel partially connected

I feel detached

Other

Additional Comments?