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Home
Services
Presentations
Media
Blog
FAQs
About
Contact
- Map and Directions
For Professionals
- Imago Consultation Group 3.0

Home
Services
Presentations
Media
Blog
FAQs
About
Contact
- Map and Directions
For Professionals
- Imago Consultation Group 3.0

08 Jan 2026 Mike DiPaolo

The Couple Questionnaire

Name*
First Last
Date*
MM slash DD slash YYYY
E-Mail Address*
Partner Name*
Length of Relationship*
Do you have any children?*
- Yes
- No
Please give names and ages
The remainder of items on this first page asks for information about you. The second and third pages ask about your relationship.
Occupation*
Religion/Spirituality*
Do you have any current or past medical conditions?*
- Yes
- No
Please describe
Do you have any current or past mental health issues (including anxiety, depession, etc.)?*
- Yes
- No
Please describe
Do you have any addictions?*
- Yes
- No
Please describe
Are you taking any medications?*
- Yes
- No
Please describe

The following is a list of areas which 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.
Your friendship*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Quality time together*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Demonstrations of affection*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Sexual relationship*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Trust or jealousy*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Communication*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Moodiness/temper/emotionality*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Aims, goals, priorities, major life decisions*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Managing the home/chores*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Career decisions or work*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Work-life balance*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Managing finances*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Children or parenting*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Extended family (in-laws, relatives)*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied

Religion/sprituality*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Social behavior or appearance*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Use of technology – cell phones, TV, computer, video games, etc.*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Pornography*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Other addictive behavior (eating issue, gambling, etc.)*
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Other concern:
- Very Unsatisfied
- Unsatisfied
- Neutral
- Satisfied
- Very Satisfied
Overall satisfaction with your relationship (0-10)*
Please enter a number from 0 to 10.
I am committed to our relationship (0-10)*
Please enter a number from 0 to 10.
I am committed to doing all I can, including this couple therapy, to address our current issues (0-10)*
Please enter a number from 0 to 10.

What will your relationship look like if our work together is wildly successful?*
What are you (not your partner) doing now that keeps you from having the relationship that you long for?*
What could you (not your partner) do differently that would help you create that relationship?*
Please describe a recent interaction between you and your partner that is typical of the positive features of your relationship.*
Are there any additional comments that you would like to make?
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Michael DiPaolo, Ph.D.

11704 Wilshire Blvd., Suite 245
Los Angeles, CA 90025
(310) 268-7792

Email

PSY16269

Certified Imago Relationship Therapist

Internal Family Systems (IFS) Therapist

Michael DiPaolo, Ph.D.