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Relationship Report Card
My Partner...
| 1. |
is an equal participant with chores/children. |
A B C
D F NA |
| 2. |
shares in decision making. |
A B C
D F NA |
| 3. |
communicates emotions and feeling. |
A B C
D F NA |
| 4. |
gives Feedback in a positive manner. |
A B C
D F NA |
| 5. |
keeps commitments and promises. |
A B C
D F NA |
| 6. |
remembers and celebrates occasions. |
A B C
D F NA |
| 7. |
gives compliments and approval. |
A B C
D F NA |
| 8. |
is supportive of my choices and needs. |
A B C
D F NA |
| 9. |
spends sufficient time with me. |
A B C
D F NA |
| 10. |
encourages my occasional time with friends. |
A B C
D F NA |
| 11. |
is a good listener. |
A B C
D F NA |
| 12. |
can laugh and take things easy. |
A B C
D F NA |
| 13. |
is sexually responsive. |
A B C
D F NA |
| 14. |
is physically affectionate. |
A B C
D F NA |
| 15. |
is verbally affectionate. |
A B C
D F NA |
| 16. |
is polite to my parents/family. |
A B C
D F NA |
| 17. |
helps handle problems in my life. |
A B C
D F NA |
| 18. |
makes me feel loved. |
A B C
D F NA |
| 19. |
puts me (and our family) over work. |
A B C
D F NA |
| 20. |
pays attention to grooming and appearance. |
A B C
D F NA |
| 21. |
is positive and up-beat. |
A B C
D F NA |
| 22. |
doesn’t use others to get at me. |
A B C
D F NA |
| 23. |
is accepting of my shortcomings. |
A B C
D F NA |
| 24. |
treads gently where I am not strong. |
A B C
D F NA |
| 25. |
cooperates on parenting strategies. |
A B C
D F NA |
| 26. |
responds productively to criticism. |
A B C
D F NA |
| 27. |
expresses anger constructively. |
A B C
D F NA |
| 28. |
is able to handle worry effectively. |
A B C
D F NA |
| 29. |
is good with money. |
A B C
D F NA |
| 30. |
is interested in my work. |
A B C
D F NA |
| 31. |
is willing to discuss problems. |
A B C
D F NA |
| 32. |
is positive with the children. |
A B C
D F NA |
| 33. |
is emotionally and physically faithful. |
A B C
D F NA |
| 34. |
is able to compromise on issues. |
A B C
D F NA |
| 35. |
Is happy with his/her life. |
A B C
D F NA |
| 36. |
shares many of the same interests. |
A B C
D F NA |
| 37. |
is not verbally or physically threatening. |
A B C
D F NA |
| 38. |
gets along with his/her family. |
A B C
D F NA |
| 39. |
is off the phone when I am around. |
A B C
D F NA |
| 40. |
enjoys our (my) children. |
A B C
D F NA |
| 41. |
can take a “time out” when fighting. |
A B C
D F NA |
| 42. |
accepts me for who I am. |
A B C
D F NA |
| 43. |
pays attention to me when with others. |
A B C
D F NA |
| 44. |
offers to help. |
A B C
D F NA |
| 45. |
shows appreciation for what I do. |
A B C
D F NA |
| 46. |
creates time to be alone together. |
A B C
D F NA |
| 47. |
handles “Ex” in an appropriate manner. |
A B C
D F NA |
| 48. |
is compatible on religious issues. |
A B C
D F NA |
| 49. |
trusts me. |
A B C
D F NA |
Current Assessment
What are the problems in your marriage? _______________________________
_______________________________________________________________
What specific incident caused you to decide to come to marriage counseling at
this time?
__________________________________________________________________
What are your partner’s strengths? _______________________________________
__________________________________________________________________
If you had a “magic wand,” what would you change about your partner?
__________________________________________________________________
__________________________________________________________________
Please check the sentence that most describes your relationship:
_____ Overall, I am very happy in our marriage.
_____ I rarely consider divorce.
_____ It is hard to imagine things changing much.
_____ I often consider a separation or divorce.
_____ I am here to arrange a separation/divorce.
Please rate the following sentences.
1. I am willing to do almost anything to make our relationship work.
_____ _____
_____ _____
_____
Very True Mostly True Neutral Mostly False Very False
2. Over the relationship, we were never truly happy together.
_____ _____
_____ _____
_____
Very True Mostly True Neutral Mostly False Very False
Please finish this sentence: An ideal marriage is one where ____________________
__________________________________________________________________
__________________________________________________________________
Relationship History
What attracted you to your spouse? ______________________________________
__________________________________________________________________
What were the warning signs of your current problems?
__________________________________________________________________
Is your spouse more like your mother or your father? How? _____________________
__________________________________________________________________
Are you more like your mother or your father? How? __________________________
__________________________________________________________________
With which parent did you have more conflict? Explain.
________________________
__________________________________________________________________
What did you learn about relationships by watching your parents?
________________
__________________________________________________________________
Wilmes-Reitz Psychological
23945 Calabasas Rd., Suite 202
Calabasas, California 91302
(818) 591-8270
wrpsych@aol.com
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