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Relationship Coaching Survey #2

If you are not currently in an intimate relationship, this is the survey for you to complete. If you are in an intimate relationship, please complete Relationship Coaching Survey #1.

Please respond to the following statements by checking 1, 2, 3, 4, 5, or NA.

 The scale is:

1 -Strongly Agree,  2 -Agree,  3 -Neutral,  4 -Disagree,  5 -Strongly Disagree,
NA -Doesn't Apply

You may choose to submit your score at the bottom of this page.

1.

I have confidence in finding a partner who is a good and healthy match for me.

1

2

3

4

5

NA

2.

I have recovered from past disappointing or hurtful relationships. 

1

2

3

4

5

NA

3.

I can be playful and have fun in an intimate relationship.

1

2

3

4

5

NA

4.

I trust that my own communication skills help to build up my partner rather than tear him/her down. 

1

2

3

4

5

NA

5.

I believe I have the ability to resolve conflicts with a partner in a way that satisfies us both and allows for forgiveness if we've been hurt. 

1

2

3

4

5

NA

6.

I can be angry without trying to hurt my partner.

1

2

3

4

5

NA

7.

I have had a satisfying sexual relationship in the past. 

1

2

3

4

5

NA

8.

I expect to be comfortable with me and my partner having activities and friendships that don't include each other. 

1

2

3

4

5

NA

9.

I feel capable of fully trusting a partner and of being trustworthy. 

1

2

3

4

5

NA

10.

I expect my relationship with my nuclear family to be a benefit to my future partner. 

1

2

3

4

5

NA

TOTAL SCORE:  
   

1 to 25 It sounds like you're well-prepared for a satisfying new relationship.
26 - 35 Your confidence and success in finding a healthy relationship could be
strengthened by enhancing your strengths in a few areas.
36 - 50 Your past experience has left you feeling unprepared to find and build
a satisfying new relationship. Coaching could help you develop the skills and
confidence to participate in creating a fulfilling and long-standing partnership.

Name: 
Phone:
Email: 

   

Relationship coaching can help people to develop better communication and conflict resolution skills, to improve the intimate aspects of their lives, to have a sense of play in their relationship, and to create or renew a deep sense of loving and being loved.

Please click on "Relationship Coaching" in the menu to read a description of the coaching options that might be of value to you.