Relationship Questionnaire

Please take the time to answer all questions. Each one will access something deep in yourself worth while exploring. Your emotional growth requires you to give yourself the time to feel through each one and to allow the various feelings to begin to surface. Processing each will be of great service to yourself.

Your Name

Your Email

1. What pain have you been carrying on? And for how long?

2. What hurts right now?

3. Where do you hurt?

4. Where are you feeling stuck at this moment?

5. What feels different to you right now and/or in your relationship?

6. Are any of these feelings currently present? Shame- Guilt -Anger- Regret -Resentment?

7. Are you willing to let go of these feelings?

8. What needs to happen to let them go?

9. What or whom do you need to forgive?

10. What are you not forgiving?

11. Are you aware of how you have contributed to the way you are currently feeling?

12. What is the emotional pattern that keeps showing up for you or in your relationship (s)?

13. In the past, how do you usually deal with difficult emotions?

14. How do you express (or not express) anger and pain?

15. In the last 6 months what would you consider the greatest stressor (s) in your life or in your relationship?

16. How have you change?

17. Who have you become recently?

18. What do you tend to be most familiar with feeling overwhelmed or abandoned?

19. Whose “love and attention” did you crave most growing up? – your mother’s or father’s?

20. Describe the person you became for him/her?

21. Why now? (Seeking help)

22. Do you know what you want?

23. If this therapy is to be successful, what do you want to experience yourself or with your partner?