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This is the LAST part of the assessment. It is rather short, compared to the part you’ve already completed. You can come back to it later if you like. It asks a lot of personal information, which is all confidential.

Your clinician will receive your results and use them to help this process continue moving quickly.

This portion should take you about 20 minutes….

Your Name:
Your email address
1. I have made specific plans to discuss separation (or divorce) with my spouse.  I have considered what I would say, etc.
2. I have set up an independent bank account in my name in order to protect my own interests.
3. Thoughts of separation (or divorce) occur to me very frequently, as often as once a week or more.
4. I have suggested to my partner (spouse) that I wished to be separated, divorced, or rid of him/her.
5. I have thought specifically about separation (or divorce). I have thought about who would get the kids, how things would be divided, pros and cons, etc.
6. My partner and I have separated. This is a (check one) ___ trial separation or ___ legal separation.

 

7. I have discussed the question of my separation (or divorce) with someone other than my spouse (trusted friend, psychologist, minister, etc.).
8. I have occasionally thought of separation (or divorce) or wished that we were separated, usually after an argument or other incident.

 

9. I have discussed the issue of separation (or divorce) seriously or at length with my spouse.
10. We are separated, I have asked that the separation be permanent (or filed for divorce), or we are completely broken up (or divorced).
11. I have made inquiries about separation (or how long it takes to get a divorce, grounds for divorce), costs involved, etc.

 

12. I have contacted a lawyer to make preliminary plans for a separation or custody arrangement (or divorce).
13. I have consulted with a lawyer or other legal aid about the whole matter.
14. I have considered separation (or divorce) a few times, other than during or after an argument, although only in vague terms.
SUICIDE POTENTIAL
 
1. Have you ever attempted suicide?
2. Have you ever planned a suicide attempt?
3. Are you currently thinking about suicide?
If yes, then how often?
Daily
4. Does the following describe you at the moment?
“I would like to kill myself”
“I would kill myself if I had a chance”
5. Do you currently have a suicide plan?   

Relationship Behaviors - Please indicate how often each of the items happened in the past 6 months:

In the past 6 months, has your partner hit you?
In the past 6 months, has your partner twisted your arm or hair?
In the past 6 months, have you had a sprain, bruise or small cut because of a fight with your partner?
In the past 6 months, has your partner pushed or shoved you?
In the past 6 months, has your partner grabbed you?
In the past 6 months, has your partner slapped you?
In the past 6 months, has your partner used a knife or gun on your?
In the past 6 months, has your partner injured you?
In the past 6 months, has your partner punched or hit you with something that could hurt?
In the past 6 months, have you gone to the doctor because of a fight with your partner?
In the past 6 months, has your partner choked you?
In the past 6 months, has your partner beat you up?
In the past 6 months, has your partner burned or scalded you on purpose?
In the past 6 months, has your partner slammed you against a wall?
In the past 6 months, has your partner kicked you?
I needed to see a doctor because of a fight with my partner, but I didn’t
I had a broken bone from a fight with my partner.
In the past 6 months, my partner used force (like hitting, holding down, or using a weapon) for me to have sex.  
In the past 6 months, my partner used threats to make me have sex.

In the past 6 months did your partner:

Try to control your every move?    
Withhold money, make you ask for money, or take your money?   
Threaten to kill you?
Threaten to hurt your family, friends, or pets?   
Refuse to take responsibility for violent behavior, putting the blame on you?
Try to isolate you by keeping you away from your family or friends?  
Stalk or harass you or someone else at work or elsewhere?   

 

Fear of Partner as a potential result of Therapy

Are you afraid of your partner?          
Are you uncomfortable talking in front of your partner?   
Do you worry that therapy might lead to violence?

Emotional Abuse Read each statement, and circle the word that best describes the frequency with which each behavior occurs.

1. I have to do things to avoid my partner’s jealousy.
2. My partner tries to control who I spend my time with.
3. My partner repeatedly accuses me of flirting with other people.
4. My partner is overly suspicious that I am unfaithful.
5. My partner acts like a detective, looking for clues that I’ve done something wrong.
6. My partner keeps me from going places I want to go.
7. My partner threatens to take the money if I don’t do as I am told.
8. My partner forcibly tries to restrict my movements.
9. My partner tries to control all my money.
10. My partner tries to control all my freedom.
11. My partner tries to convince other people that I’m crazy.
12. My partner has told me that I am sexually unattractive
13. My partner insults my family.
14. My partner humiliates me in front of others.
15. My partner makes me do degrading things.
16. My partner intentionally does things to scare me.
17. My partner threatens me physically during arguments.
18. My partner warns me that if I keep doing something violence will follow.
19. My partner makes me engage in sexual practices I consider perverse.
20. In bed my partner makes me do things I find repulsive.
21. I feel pressured to have sex when I don’t want to.
22. My partner threatens to hurt someone I care about.
23. My partner intentionally damages things I care about.
24. My partner does cruel things to pets or other animals.
25. My partner threatens to hurt my children.

   

DRUG AND ALCOHOL SCREENING TEST

What we mean by the term “drugs”: Opiates (for example, morphine, codeine, heroin), Depressants (for example, barbiturates), Stimulants (for example, cocaine, amphetamines), Hallucinogens (for example, LSD, Mescaline), Marijuana, Hashish, other illegal substances (for example, Psilocybin, DMT, DET, PCE, PCP, TCP)

Please respond to each item for yourself and your partner:
 * You
* Partner

 

How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?

 

In a typical week how many days do you have at least one alcoholic drink? (or answer for a typical week in which you do drink)

 

How often do you have six or more drinks on one occasion?

 

Do you use drugs other than those required for medical purposes?
Have you abused prescription drugs?

 

Do you use more than one drug at a time?
Can you get through a week without using drugs?

   

   

1. CHAOS Instructions. Circle True or False for each item below.

1. Does your home life together feel chaotic? 
2. Is there any sense of disorder in your life together?
3. In this relationship are you unable to function well in your own life?
4. Do major unplanned events keep happening to the two of you? 
5. Are the two of you always having to adapt to changing circumstances?
6. Do you sometimes feel personally out of control of your life?
7. Do you sometimes feel like a “feather in the wind” in this relationship?
8. Is it hard for you both to work regularly?
9. Is it hard for the two of you to maintain a regular and reliable schedule?
10. Does your financial life seem unstable?
11. Do your finances feel out of control?
12. Do the two of you have trouble eating well (nutritiously)?
13. Have the two of you been unable to have a routine for grocery shopping?
14. Have the two of you been unable to have a regular routine for meals?
15. Have the two of you been unable to maintain good health?

2. TRUST  Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either Strongly Disagree, Disagree, Neither agree nor disagree, Agree, Strongly Agree.

1.There were important times when my partner has not been there for me emotionally when I was really in need.
2. My partner has been or is emotionally involved with someone else, which feels like a betrayal.
3. My partner has been or is sexually involved with someone else, which feels like a betrayal.
4. I don’t have much trust in any relationship.
5. Once, when I really needed to turn to my partner for emotional support, I was terribly disappointed and left utterly alone.
6. Sometimes I don’t feel important to my partner.
7. My partner has forced me to do some things against my principles, or to do things that I find objectionable, repulsive, or disgusting.
8. My partner lies to me.
There are some wounds my partner has created that can never fully heal between us.
9. My trust in this relationship has been seriously shattered.
10. I don’t feel that I am my partner’s first, or even major, priority in his or her life.
11. My partner has cheated me and I feel betrayed by that.
12. My partner has betrayed me financially.
13. When going through hard times in our relationship, I don’t feel I can count on my partner to be there for me.
14. Our vows aren’t really sacred to my partner.
15. My partner can be deceitful with me in many ways
16. When I get sick I am abandoned by my partner.
17. I can’t really count on my partner.
18. If I should have financial problems, my financial problems are totally my own. I cannot rely on my partner to help me out.
19. I suspect that my partner has betrayed our relationship contract in the past.
20. My partner is not really loyal to me.

3. COMMITMENT

Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either SD for Strongly Disagree, D for Disagree, N for Neither agree nor disagree, A for Agree, and SA for Strongly Agree.

1. I feel confident that my partner will stay in this relationship even if we are going through hard times. 
2. When I am feeling bad my partner is willing to meet my needs.
3.  During a fight my partner does not threaten to leave me.
4.  I am committed to this relationship.
5.  I consider my relationship rock solid
6. I would refuse to have sex with a person other than my partner.
7. I will sometimes make major sacrifices for my partner even if it goes against what I need.
8. I make sure that my partner feels loved by me.
9. When my partner is sick I think it is very important that I take care of him or her.
10. When I compromise with my partner I don’t feel controlled and manipulated.
11. Being a team is sometimes more important to me than my own needs.
12. I feel that my partner’s financial security is in part my responsibility.
13. If my partner were in emotional trouble I would be there 100 percent.
14. After an argument I am not thinking that I could be happier with someone else.
15. During a fight I do not threaten to leave my partner.
16. I am not waiting for someone better to come along.
17. We are not usually engaged in a power struggle.
18. I want to stay with my partner forever.
19. I would avoid flirting if it made my partner feel insecure.
20. No matter what’s going on, I never fantasize about divorce or separation.
21. No matter how bad things get I never long for the days when I was single.
22. I never envy my friends who are single.
23. I never fantasize about what life would be like being someone else’s partner.
24. I love it when my partner and I dream about our future together.
25. I love thinking about my partner and I growing old together.
26. My worst nightmare is my partner dying before me.
27. I feel loved by my partner.

4. YOUR OWN FEELINGS ABOUT EMOTIONS (META-EMOTIONS) What’s your emotion philosophy? Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either SD for Strongly Disagree, D for Disagree, N for Neither agree nor disagree, A for Agree, and SA for Strongly Agree.

1. I try not to think much about my own emotional states
2.  I believe that people should just roll with the punches and get on with life
3. There’s not much point in dwelling on your inner feelings
4. I generally view being emotional as being out of control
5. People ought to be more rational and less emotional
6. Anger is a very dangerous emotion
7. People often act emotional just to get what they want
8. If you ignore negative emotions they tend to go away and take care of themselves
9. It is best to just “ride out” negative emotions and not dwell on them
10. I don’t mind other people’s negative moods as long as they don’t last too long
11. I set some definite limits on other people’s staying in a negative emotional state
12. I really don’t want to experience negative emotions
13. It isn’t important to dwell on why you are feeling the way you feel
14.  When people get sad they are just feeling sorry for themselves
15.  I think if you want to you can make yourself feel positively about almost anything
16. I am not sure anything can be done when someone is feeling down
17. It is unnecessary to look deeply at the causes of one’s emotions
18. I just try not to make a big deal out of my own emotions
19. There is very little to be gained by dwelling on why one is feeling a certain way
20. People can definitely not tell what I am feeling
21. Anger is always a very toxic emotion
22. Feelings are private and I try not to express them outwardly
23. There’s not much difference between anger and aggression
24. Expressions of affection are usually embarrassing for me
25. Generally I am fairly neutral and don’t experience very much emotion
26. Sadness is a form of weakness
27. Ideally, it is better to stay in control, upbeat, and positive
28. If people are emotional they may lose control
29. People ought to know when you love them without your having to say so
30. Dwelling on your fears just is an excuse for not getting things done
31. In general it’s better not to express your sad feelings
32. I’m not sure that there’s much that can be done to change strong negative feelings
33. Trying to problem solve with an emotional person is a waste of time
34. When my partner is angry it means there is something wrong with our relationship
35. Just the passage of time solves most things

5. FLOODING
Read each statement and place a check mark in the appropriate TRUE or FALSE box.

Our discussions get too heated.
I have a hard time calming down.
One of us is going to say something we will regret.
I think to myself, “Why can’t we talk more logically?”
My partner has a long list of unreasonable demands.

6. MY FAMILY HISTORY We’d like to ask you some questions about stresses and supports you experienced as a child growing up in your family.  Please answer these questions as honestly as you can.  Indicate the number next to each item that is how you feel about the item’s truth for your life using the following scale: 5= Strongly agree, 4=Agree, 3=Neutral, 2=Disagree, 1=Strongly Disagree

The family I grew up in struggled financially. 
I was physically abused by my parent(s). 
My relationships with my siblings were not close.   
I was sexually abused or molested in my family.
My family home was a place of instability and insecurity.  
My family moved too often. 
My parents were not affectionate toward me. 
One or both of my parents were alcoholic. 
My parents were unhappy with one another. 
I never really trusted my parents. 
My parents had no faith in my abilities. 
My parents didn’t praise me very much. 
My parents didn’t often show me that they loved me. 
I was lonely as a child. 
My parents didn’t protect me from danger very well. 
We didn’t travel very much together as a family.
Growing up I could never talk to my parents about my feelings. 
My home was very chaotic. 
My parents used unnecessarily strict and harsh discipline. 
It was never okay for me to tell my parents what my needs were. 
I was not accepted by my peers. 
My parents would use shame, or belittle me.
There was no love and affection expressed in my family. 
Ours was not a child-centered home. 
The kids were ignored by my parents. 
There was lots of rivalry between my siblings.
My home was not open socially to guests and visitors. 
My parent(s) used illicit drugs or alcohol.
My parents forced me to do a lot of chores. 
There was lots of conflict in my family.
My parents gave me very little freedom to explore my interests.
I experienced cruelty from my family. 
I was physically abused by my parents.
I witnessed violence between my parents or adults in my family. 
I had no supportive teachers at school.
I didn’t have a sense of belonging in my family. 
I experienced abuse or bullying from peers at school.
My parents were not understanding and empathic toward my feelings. 
My father was not present, or absent a lot. 
My parents were emotionally volatile. 
I often got blamed when something went wrong at school. 
I had no good friends growing up.
My parents rarely came to my own special events.
My parents had bad temper outbursts. 
I didn’t get the attention I needed growing up.
My father was a cold person. 
My parents were neglectful. 
My parents never really knew me well. 
There was a lot of tension in my home growing up.
My mother was a cold person. 
I was given lots of choices as a kid. 
I was physically hungry as a kid.
I never really got to know my father. 
I rarely look forward to family gatherings or visits from relatives.
We are not a strong or unified family.
I never took fun vacations with my family. 
My family was not emotionally expressive.
My parents were strict and authoritarian. 
I dislike my some of brothers or sisters.
I am competitive with one or more of my sibling.
My family was not active in the community. 
It was never okay for me to make mistakes. 
I was compared unfavorably to others by my parents. 
My parents were too perfectionist.
My mother and father were critical of me. 
We did not eat usually eat together as a family. 
We rarely had fun family holidays together.
My preferences as a kid were usually ignored. 
My birthdays were never well celebrated. 
My siblings were not given preference over me. 
My parents’ discipline was inconsistent. 
My parents were financially stingy toward me. 
There was no music in our home. 
There was no laughter in my home growing up. 
I couldn’t usually come to my parents and ask for help.
I rarely had friends over to my house.
We rarely had fun together as a family.
We rarely played together as a family. 
If I had a problem as a kid, I usually kept it to myself. 

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