Intake questions

Essential information for me to start working with you as a couple are firstly, tender, self-reflective answers to these five questions:

1. Describe the distressing pattern or patterns that you keep repeating as a couple? These are described as demon dances in the recommended book “Hold Me Tight” by Susan Johnson.(a good review on that link but ignore the ads)

2. Track the beginning, middle and end of one or more of these cycles, and describe the sensations in your body, thoughts in your head and the feelings that arise as a result?

3. What is your singular contribution to starting and maintaining the most challenging of these cycles?

4. How do you pause or end the process?

5. How do you repair our relationship after the crash, or not?

Here is an article by Susan Johnson, which summarises her work presented in Hold Me Tight.

Secondly, here is an intimate relationship engagement scale for you to fill out and send me.

This scale can be filled out by each of you separately. Try to rate each item with your most honest and realistic answer. Do not answer how you wish the relationship could be, or how it has been at previous times, but how it has been within the last 6 months. Each item asks you to make a generalization, so do your best to think in overall terms from the last 6 months rather than about one or two specific instances. 

Please fill out all items and use the 1–7 rating scale provided below. Please print this section, and circle the numerical rating that best applies to each item.
1=not at all, 4=somewhat, 7=very much.

(1) We discuss domestic chores and make a fair division of duties.
1 2 3 4 5 6 7

(2) We discuss and agree on major time commitments before making them (e.g., work schedules, business trips, social events, appointments, separate outings with friends, etc.).
1 2 3 4 5 6 7

(3) We openly discuss and agree on all financial resources and decisions (e.g. joint checking, big ticket purchases, shared mortgage, pooled investment, mutual beneficiaries, etc.).
1 2 3 4 5 6 7

**IF YOU HAVE CHILDREN PLEASE ANSWER QUESTION 4. IF YOU DO NOT HAVE CHILDREN PLEASE ANSWER QUESTION 4A.
(4) We discuss, reach agreement, and present a unified front about child-rearing decisions (e.g., discipline, privileges, academic goals, etc.).
1 2 3 4 5 6 7

(4A) We have discussed and are in agreement about our current stance toward hav- ing children.
1 2 3 4 5 6 7

(5) We communicate about and share a mutually satisfying sexual relationship.
1 2 3 4 5 6 7

(6) We have achieved a balance between pursuing recreational activities together and also giving each other space to pursue independent activities. we 
1 2 3 4 5 6 7

(7) We communicate about our deepest fears and vulnerabilities to each other.
1 2 3 4 5 6 7

(8) We regularly (i.e., at least once a week) set aside time of 30 min or more that is exclusively for us as a couple, to talk, share an activity, or simply hang out together.
1 2 3 4 5 6 7

(9) We discuss and continue to develop plans for how our life together might be over the next 10 years and beyond.
1 2 3 4 5 6 7

(10) We discuss and reach agreement about how to relate to and interact with extended family (e.g., in-laws, uncles, aunts, cousins, etc.).

1 2 3 4 5 6 7

Source of this questionnaire