Michael DiPaolo, Ph.D.

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Partner's Name*

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The following is a list of areas that can bring couples closer together or lead to disagreements or dissatisfaction. Please fill in the bubble which represents your level of satisfaction in each area.

Questionnaire

	Very Dissatisfied	Dissatisfied	Neutral	Satisfied	Very Satisfied
Your friendship
Quality time together
Demonstrations of affection
Sexual relationship
Trust or jealousy
Communication
Moodiness/temper/emotionality
Aims, goals, priorities, major life decisions
Managing the home/chores
Career decisions or work
Work-Life Balance
Finances
Children or parenting
Extended family (in-laws/relatives)
Religion/Spirituality
Social behavior or appearance
Use of technology (cell phone, TV, computer, video games, etc.)
Alcohol or drugs
Pornography

Other

List and rate any additional area you would like

Overall satisfaction with your relationship

Clinical Psychologist

Certified Imago Relationship Therapist

The Marriage Tune-Up!

Marriage Tune-Up

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Michael DiPaolo, Ph.D.

Certified Imago Relationship Therapist

Internal Family Systems (IFS) Therapist