How many hours of Face-to-Face time do you and your partner get on average in a week? (Face-to-Face time means just the two of you with no screens and not discussing logistics)
*
4 hours or less
5 or more hours
Do you and your partner sleep in the same bed?
*
Yes
No
Do you or your partner keep important things private from each other? (For example, finances)
*
No, we share everything with each other
Yes, at least one of us keeps important things private from the other
Do you and your partner allow each other access to your phone, email, and social media accounts?
*
Yes, we allow each other access to those things
No, we do not allow each other to access those things
How often are you and your partner intimate?
*
At least once a week
At least once a month
Once every few months
Less frequently than above
When you are upset, who do you turn to first for help?
*
My partner
My friend(s)
My parent(s)
My child/children
Nobody
When your partner is upset, who does he or she turn to first for help?
*
Me
His or Her friend(s)
His or Her parent(s)
His or Her child/children
Nobody
Do you share a common vision with your partner?
*
Yes
No
Have you or your partner ever had an affair?
*
Yes
No
Do you feel safe in your relationship?
*
Yes
No
Do either you or your partner struggle with addiction?
*
Yes
No
First Name
*
Last Name
Email
*
Phone
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