Name * First Name Last Name Email * 1. Describe how much significant time you spend together as a couple and when you spend it. * 2. Describe five behaviors or tasks your spouse does that you appreciate * 3. How frequently do you affirm or reinforce your spouse for the behaviors or tasks in the qualities described in questions 2 and 3? 4. List three expectations you have for your spouse. Indicate with a " * ", which are being met at this time. 5. List three expectations your spouse has of you. Indicate with a " * ", which are being met at this time. * 6. What do you do to let your spouse know that you love him or her? * 7. What does your spouse do to let you know that he or she loves you? Goals for Your Marriage 1. List three marital goals you have for the next year. * 2. List three marital goals you have for the next five years. * How Can You Change Your Marriage 1. Think of an issue you would identify as a problem in your marriage and describe it. * 2. When doesn’t this problem happen? * 3. What is different about these times? * 4. How do you think differently? * 5. If you woke tomorrow with these problems solved, what would you be doing differently? * Current Level of Satisfaction Select the radio button to indicate your level of satisfaction, with 0 meaning no satisfaction, 5 average and 10 super, fantastic, the best. Use the text below each question to indicate what you think your spouse’s level of satisfaction is at the present time. 1. Our daily personal involvement with each other: * 0 1 2 3 4 5 6 7 8 9 10 2. Our affectionate, romantic interaction: * 0 1 2 3 4 5 6 7 8 9 10 3. Our sexual relationship * 0 1 2 3 4 5 6 7 8 9 10 4. The frequency of our sexual contact: * 0 1 2 3 4 5 6 7 8 9 10 5. My trust in my spouse" * 0 1 2 3 4 5 6 7 8 9 10 6. My spouse’s trust in me: * 0 1 2 3 4 5 6 7 8 9 10 7. The depth of our communication together: * 0 1 2 3 4 5 6 7 8 9 10 8. How well we speak one another’s love language: * 0 1 2 3 4 5 6 7 8 9 10 9. How we divide chores: * 0 1 2 3 4 5 6 7 8 9 10 10. The way we make decisions: * 0 1 2 3 4 5 6 7 8 9 10 11. How we manage conflict: * 0 1 2 3 4 5 6 7 8 9 10 12. Adjustment to one another’s differences * 0 1 2 3 4 5 6 7 8 9 10 13. Amount of free time spent together: * 0 1 2 3 4 5 6 7 8 9 10 14. Quality of free time spent together * 0 1 2 3 4 5 6 7 8 9 10 15. Amount of free time spent apart: * 0 1 2 3 4 5 6 7 8 9 10 16. Our interaction with friends as a couple: * 0 1 2 3 4 5 6 7 8 9 10 17. The way we support each other in rough times: * 0 1 2 3 4 5 6 7 8 9 10 18. How we support each other’s careers * 0 1 2 3 4 5 6 7 8 9 10 19. Our spiritual interaction * 0 1 2 3 4 5 6 7 8 9 10 20. Our church involvement * 0 1 2 3 4 5 6 7 8 9 10 21. The level of our financial security * 0 1 2 3 4 5 6 7 8 9 10 22. How we manage money * 0 1 2 3 4 5 6 7 8 9 10 23. My spouse’s relationship with my relatives * 0 1 2 3 4 5 6 7 8 9 10 24. My relationship with my spouse’s relatives * 0 1 2 3 4 5 6 7 8 9 10 Scoring Key To determine your score, add the numbers you selected for each statement. The sum reflects your score. 192-240 Your relationship is doing very well. 144-191 Your relationship has some major strengths. 121-143 You have strengths and weaknesses. Any satisfaction under six would benefit from some work. 73-120 Definite improvement needed. 72 and lower Major assistance is needed as soon as possible Current Level of Communication Select between 1 to 5 to indicate your current level of communication, with 1 = almost never 2 = rarely 3 = sometimes 4 = often 5 = almost always. 1. Listens when the other person is talking * 1 2 3 4 5 2. Appears to understand spouse when he/she shares * 1 2 3 4 5 3. Tends to amplify and say too much * 1 2 3 4 5 4. Tends to condense and say too little * 1 2 3 4 5 5. Tends to keep feelings to oneself * 1 2 3 4 5 6. Tends to be critical or nag * 1 2 3 4 5 7. Encourages spouse * 1 2 3 4 5 8. Tends to withdraw when confronted * 1 2 3 4 5 9. Holds in hurts and becomes resentful * 1 2 3 4 5 10. Lets spouse have say without interrupting * 1 2 3 4 5 11. Remains silent for long periods of time when the other is angry * 1 2 3 4 5 12. Fears expressing disagreement if the other becomes angry * 1 2 3 4 5 13. Expresses appreciation for what is done most of the time * 1 2 3 4 5 14. Complains that the other person doesn’t understand him or her * 1 2 3 4 5 15. Can disagree without losing his or her temper * 1 2 3 4 5 16. Tends to monopolize the conversation * 1 2 3 4 5 17. Feels free to discuss sex openly with spouse * 1 2 3 4 5 18. Gives compliments and says nice comments to spouse * 1 2 3 4 5 19. Feels misunderstood by spouse * 1 2 3 4 5 20. Tends to avoid discussions of feelings * 1 2 3 4 5 21. Avoids discussing topics or issues that are problems * 1 2 3 4 5 Scoring Key Statements 1, 2, 7, 10, 13, 15, 17 and 18 To determine your score, add the numbers you made an X through for each of these eight statements. The sum reflects your score. To determine your spouse’s score, add the numbers you circled for each of these eight statements. The sum reflects your spouse’s score. 33-40 You’re doing very well. 25-32 You’re doing well. 17-24 Some areas need improvement. 9-16 Definite improvement needed. 0-8 The relationship needs major assistance. Statements 3, 4, 5, 6, 8, 9, 11, 12, 14, 16, 19, 20 and 21 To determine your score, add the numbers you made an X through for each of these 13 statements. The sum reflects your score. To determine your spouse’s score, add the numbers you circled for each of these 13 statements. The sum reflects your spouse’s score. 53-65 The relationship needs major assistance. 40-52 Definite improvement needed. 27-39 Some areas need improvement. 14-26 You’re doing well. 8-13 You’re doing very well. Your Spiritual Relationship 1. Your church affiliation * 2. Do you have a personal faith in Jesus Christ? * Yes No 3. How frequently do you pray by yourself? * Daily Several times per week Once a week Occasionally 4. How frequently do you read Scripture by yourself? * Daily Several times per week Once a week Occasionally 5. How frequently do you and your spouse pray together? * Daily Several times per week Once a week Occasionally 6. How frequently do you and your spouse read Scripture or some devotional material together? * Daily Several times per week Once a Week Occasionally 7. How important are questions 5 and 6 to you in your marriage? * 0= Not important 5=Important 10=Very important 0 1 2 3 4 5 6 7 8 9 10 Thank you for completing your assessment. You will receive a pdf in the email you provided with all your answers to discuss with your spouse.
