Relationship Check-In Questionnaire

A screening tool to help identify areas of strength and areas of difficulty in a relationship. This is not a diagnostic instrument — results are meant to be reviewed with a licensed therapist or counselor, who will consider each partner's answers alongside clinical judgment and conversation.

Instructions: Each partner should complete this form independently and honestly, without discussing answers with each other beforehand. For each statement, select the number that best reflects your current experience of the relationship.
Scale: 1 = Strongly Disagree  •  2 = Disagree  •  3 = Neutral / Mixed  •  4 = Agree  •  5 = Strongly Agree

Communication

1. My partner and I can talk about difficult topics without it turning into a fight.

2. I feel heard and understood when I express my thoughts or feelings.

3. We check in regularly about how we're each doing, emotionally and practically.

4. I feel comfortable bringing up concerns as soon as they arise, rather than letting them build up.

Conflict Resolution

5. When we disagree, we're usually able to reach a resolution or compromise.

6. Arguments between us do not involve yelling, name-calling, or contempt.

7. After a conflict, we're able to reconnect and move forward without prolonged resentment.

8. Neither of us regularly stonewalls (shuts down/refuses to engage) during disagreements.

Trust & Honesty

9. I trust my partner to be honest with me, even about difficult things.

10. I do not feel the need to check my partner's phone, email, or whereabouts.

11. My partner follows through on commitments and promises.

12. I believe my partner has my best interests at heart.

Emotional Intimacy

13. I feel emotionally close to my partner.

14. My partner shows genuine interest in my inner life (thoughts, dreams, worries).

15. I feel safe being vulnerable with my partner.

16. We make time for each other despite busy schedules.

Physical Intimacy

17. I am satisfied with the physical affection (not limited to sex) in our relationship.

18. We are able to talk openly about our physical/sexual relationship.

Shared Values & Goals

19. My partner and I generally agree on major life goals (family, career, lifestyle).

20. We handle financial decisions in a way that feels fair to both of us.

21. We support each other's individual goals and growth outside the relationship.

Respect & Individuality

22. My partner respects my boundaries and need for personal space.

23. I feel free to be myself around my partner, without fear of judgment or criticism.

Commitment & Outlook

24. I feel optimistic about the future of this relationship.

25. Overall, I would rate my satisfaction in this relationship as high.

Additional Open-Response Questions (optional, for context)

This questionnaire is intended as a conversation-starting and screening aid for licensed mental health professionals. It is not a validated diagnostic instrument and does not screen for intimate partner violence.

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