Email *
Age
Where Are You Here Today? *
Being touched *
Touching *
Comfort with showing affection *
Ability to express feelings *
Friends/social relationships *
Sex *
Self-acceptance/love *
Self-advocacy (do you feel confident you can change things) *
Money *
Receiving support *
Stress with job *
Sleeping habits *
Eating habits *
Lingering loss/trauma issues *
Life values *
Life goals *
How did you feel at that time (about yourself, your partner)? *
When did issues begin? *
What is your hypothesis of the problem? *
What external stressors are impacting your relationship? (e.G., illness, death, $, job) *
What internal stressors are impacting your relationship? (e.G., age, loneliness, self-esteem, depression) *
What are your beliefs about partner’s love for you? *
What are your beliefs about partner’s level of commitment to you? *
How would you like to be treated differently by your partner? *
How do you want to be different in your relationship? *
What has hurt you the most in this relationship? *
What is the worst thing you have done to hurt your partner? *
Do you feel you have let your partner down? How? *
How do you treat your partner when you feel bad about yourself? *
Does your partner ever remind you of someone in your life? Why? When? *
