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Imago Consultation Group 3.0
Michael DiPaolo, Ph.D.
Menu
Home
Services
Individual Psychotherapy
Relationships & Couples
Contemplative Dating
Marriage Preparation
Couples Therapy
The Marriage Wellness Clinic
Relationship Boot Camp!
Major Mental Illness
Library
Presentations
Media
Blog
FAQs
About
Contact
Map and Directions
For Professionals
Imago Consultation Group 3.0
Home
Services
Individual Psychotherapy
Relationships & Couples
Contemplative Dating
Marriage Preparation
Couples Therapy
The Marriage Wellness Clinic
Relationship Boot Camp!
Major Mental Illness
Library
Presentations
Media
Blog
FAQs
About
Contact
Map and Directions
For Professionals
Imago Consultation Group 3.0
X
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?
CAPTCHA
Michael DiPaolo, Ph.D.