Couple Communication Assessment
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a comprehensive
Couple Communication Assessment
designed to evaluate. how well couples communicate.
Choose the response that best describes you from the following scale:
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Personal informations
First Name
*
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Last Name
*
This field is required.
Gender
*
Female
Male
This field is required.
Date of Birth (mm/dd/yy)
*
This field is required.
Religion
*
This field is required.
Email
*
This field is required.
Phone Number
*
This field is required.
Profession
*
This field is required.
Birth Order (E.g 1st out of Five, 2/5, 3/5, 5/5…)
*
This field is required.
Residential Address
*
This field is required.
Marital Status
*
Married
Separated
Divorced
Engaged
Dating
Single
Complicated
This field is required.
What is your intention for this process?
*
This field is required.
Couple Communication Assessment
1- <strong>We listen to each other without interrupting.</strong>
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Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
2- <strong>We feel safe expressing our true thoughts and emotions to each other.</strong>
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
3- <strong>When there's a disagreement, we work through it calmly and respectfully.</strong>
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Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
4- <strong>We regularly check in with each other emotionally (i.e., “How are you really doing?”)</strong>.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
5- <strong>We regularly check in with each other emotionally (i.e., “How are you really doing?”).</strong>
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
6- <strong>We express appreciation and affection through words.</strong>
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Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
7- <strong>We both feel heard and understood in our conversations.</strong>
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Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
8- <strong>We resolve issues without bringing up past mistakes unnecessarily.</strong>
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Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
9- <strong>We take responsibility for our part in communication breakdowns.</strong>
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
10- <strong>We can discuss difficult topics without becoming defensive.</strong>
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
Submit
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