Couples Diagnostic Questionnaire Name *Email Address *SecurityThe feeling of safety within the relationship whereby you feel supported by a stable and dependable other who you can rely on with a strong sense of trustI feel safe to be myself around my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI trust that my partner will support me during difficult times. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel free to express my true thoughts and emotions with my partner without fear of being judged. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner provides a safe space for me to share vulnerable feelings. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner’s actions make me feel secure about the future of our relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsValidationThe feeling of having your experiences responded to in a way that leaves you feeling seen, heard, and valued within the relationship.I feel understood by my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI believe that my feelings and experiences are acknowledged by my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner sees me as an important part of their life. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner listens to me without dismissing my feelings. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner recognises the value of my perspective and insights. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsAcceptanceThe feeling of safety to ne yourself and express your thoughts and feelings without fear of judgment or criticism for who truly are and want to be.I feel accepted by my partner for who I am, flaws and all. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI am confident that I don’t have to hide parts of myself to be loved by my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI don’t feel judged by my partner for my personal beliefs or choices. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner embraces my quirks and unique traits. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner respects the differences between us and appreciates me as I am. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsMutualityThe feeling that the other shares the same experience and understanding with emphasis on shared responsibility, co-operation and support.My partner and I share responsibilities fairly in our relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel a sense of “give and take” in my relationship with my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI experience shared emotional closeness with my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner and I work together to overcome obstacles. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner and I support each other equally in pursuing our shared and individual goals. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsAutonomyThe feeling of individuality and freedom within the relationship to be yourself, pursue your own passions, interests, and goals without feeling controlled.My partner encourages me to pursue my own goals and desires, even if they are different from theirs. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner respects my decisions and choices. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel free to follow my interests without feeling pressured to conform to my partner’s expectations. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI have room to be my own person within my relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner trusts me to make my own choices without interference. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsInfluenceThe feeling of making an impact on the other, to have a voice in the relationship and feel respected and valued as an equal partner.I believe that my ideas and opinions matter to my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that I can positively impact my partner’s life. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner considers my preferences when making shared decisions. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner values my feedback and includes me in important decisions. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner respects my input on matters that affect our relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsInitiationThe feeling you matter to your partner who has a desire to be involved with you. Signs that your partner is proactive in the relationship through initiating connection through small acts of kindness and affection to taking the lead in meaningful interactions and activities which enhance a sense of satisfaction in the relationship.My partner takes the lead in planning activities or outings for us. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner makes the effort to reach out to me asking how I am. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner surprises me by initiating acts of care or affection. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner takes the initiative to resolve conflicts or address issues with me. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner starts conversations or interactions with me which help to strengthen our connection. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsLoveThe feeling of a deep emotional connection, care, affection, and commitment to nurturing the relationship maintaining a strong sense of belonging and fulfilment.I feel loved and cared for by my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel a strong sense of affection from my partner. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel valued and cherished by my partner for who I am. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner expresses their love in ways that are meaningful to me. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner’s affection is constant and reliable. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsAppreciationThe feeling of recognition of your efforts and feeling affirmed as a significant other in the relationship whereby you feel motivated and encouraged.I feel genuinely appreciated by my partner for all that I contribute to our relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner acknowledges my efforts and contributions to our relationship. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner thanks or recognises me when I do something meaningful for them. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeI feel that my partner notices the small things I do to show my care. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeMy partner expresses gratitude for my presence in their life. *Strongly disaggreeDisagreeNeutralAgreeStrongly agreeCalculationsSubmit
