This evaluation will be helpful for me to gain a picture of what your marriage is like. Please check all those that apply to how you feel in your marriage. Please print two copies, as it is most helpful to have both spouses complete this evaluation. When necessary, circle to indicate if a statement applies to you or your partner.
Communication: __I am afraid to express thoughts, feelings, opinions freely __I don’t feel heard by my partner __my partner/I respond inappropriately at times __my partner/I act(s) disrespectfully __we do not communicate well about difficult subjects __sometimes, when we communicate, it escalates to physical violence or intimidation __I avoid communication because I am afraid it will lead to conflict __Our communication sometimes leads to verbal abuse, profanity, put-downs, etc. __Other________________________________________________________________________________
Problem Solving: __ we are often unable to identify the problem __we struggle to identify options to solve problems __we rarely discuss problems without it leading to violence or verbal abuse __we are usually not able to compromise or agree to disagree __we do not share equal say in decisions/problem solving __when conflict arises we often speak of leaving or divorce __Other________________________________________________________________________________
Emotional Intimacy: __we do not talk enough __I do not think we are honest and open with each other __I do not feel close to my partner __It seems we rarely express love to each other __we do not have enough quality time __I do not feel valued/appreciated by my partner __Other_______________________________________________________________________________
Physical Intimacy: __I am not satisfied with the quality of our sexual relationship __I am not satisfied with the frequency of our sexual relationship __I do not have orgasms __I would like to improve our foreplay __I feel there are barriers in the way of our sexual relationship __I wish we included more non-sexual touch in our lives __My partner/I have committed adultery __My partner/I have a problem with pornography __Other_______________________________________________________________________________
11222 Tesson Ferry Road, Suite 200 • St. Louis, MO 63123 • 314.221.3773 • www.morgancounselingservices.com Relationship with God: __I would like to attend a Bible study as a couple __I wish we prayed as a couple __I fear our decisions are not God-pleasing __I would like to serve God as a couple __I wish my husband were a better/different type of spiritual leader __I do not feel my partner is a good spiritual example for our children __Other________________________________________________________________________________
Church: __I would like to find a church __I do not feel comfortable serving or getting involved at our church __I wish we attended church __I do not feel comfortable with the leadership of our church __I do not feel comfortable with our relationships at church __Other_________________________________________________________________________________
Extended Family: __I have problems with our visits to see extended family (length of stay, activities, where we stay, etc.) __I do not like the way we communicate with our extended family __I have concerns about fairness with our extended family __I disagree with my partner about the level of involvement of our extended family __I think we need more boundaries with our extended family __Other________________________________________________________________________________
Household Tasks: __we have unfair distribution of household tasks __I feel used and/or taken advantage of for the work I do at home __I resent my partner due to household tasks __I would like my partner to help more __Other________________________________________________________________________________
Financial: __our income is a problem __we have debt that bothers me __our spending is a problem __I worry about the fact that we are not saving for our future __we do not save to my satisfaction __My partner/I have a problem with gambling __we do not tithe even though I would like to __We do not have a satisfactory budget __I worry about the fact that we are not saving for our kid’s future __Other________________________________________________________________________________
Parenting: __I do not like the way we discipline our children __I have concerns about our children’s child care __I have concerns about how we spend quality time with our children __I have concerns about our children’s schooling __I have a problem with the way my in-laws/extended family interact with our children __Other________________________________________________________________________________
11222 Tesson Ferry Road, Suite 200 • St. Louis, MO 63123 • 314.221.3773 • www.morgancounselingservices.com Work: __I am not satisfied with my job __My work schedule interferes with my marriage __I feel like I work too much __Other________________________________________________________________________________ _________
Physical Health: __I have not had a regular check up recently __I do not exercise __I have not been to the dentist in a year or more __I do not have proper nutrition/weight __I am aware of things I should do for my health, but I don’t do them __Other________________________________________________________________________________
Mental Health: I believe my partner or I (circle which) suffer from: __Depression P/I __Anger Problem P/I __Anxiety P/I __Low self-esteem P/I __Addiction Specify_____________ P/I __Perfectionism P/I __Eating Disorder P/I __Other________________________________________________________________________________
Socializing/Hobbies: __I wish we went out as a couple more __I do not enjoy the things we do for fun __I wish we shared more hobbies or common interests __We rarely laugh together __I wish we were able to participate in individual activities more __I do not feel comfortable with the people we socialize with __Other________________________________________________________________________________
11222 Tesson Ferry Road, Suite 200 • St. Louis, MO 63123 • 314.221.3773 • www.morgancounselingservices.com
