Couple Communication Assessment
There was an error trying to submit your form. Please try again.
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
*
This field is required.
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-
We listen to each other without interrupting.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
2-
We feel safe expressing our true thoughts and emotions to each other.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
3-
When there’s a disagreement, we work through it calmly and respectfully.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
4-
We regularly check in with each other emotionally (i.e., “How are you really doing?”)
.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
5-
We regularly check in with each other emotionally (i.e., “How are you really doing?”).
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
6-
We express appreciation and affection through words.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
7-
We both feel heard and understood in our conversations.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
8-
We resolve issues without bringing up past mistakes unnecessarily.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
9-
We take responsibility for our part in communication breakdowns.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
10-
We can discuss difficult topics without becoming defensive.
*
Strongly disagree
Neutral
Strongly agree
Disagree
Agree
This field is required.
Submit
There was an error trying to submit your form. Please try again.
Crafted with ♡ SureForms