1. How long has your marriage been troubled?
A. For less than a month
B. For half a year
C. For about a year
D. For more than a year
2. When was the last time you were intimate with your spouse?
A. Within the last week
B. Weeks ago
C. Months ago
D. Can't even remember
3. Do you two have children together?
A. Yes, two or more
B. Yes, one
C. No, but we were planning
D. No, and I couldn't imagine us having children
4. Do you still live together?
A. Yes, we sleep in the same bed
B. Yes, but we sleep in different rooms
C. Yes, but we have plans for separation
D. No
5. Have you and your spouse ever discussed divorce or separation?
A. Never
B. A few times
C. Multiple times
D. We already are separated
6. How often do you have major disagreements?
A. Almost never
B. A few times a month
C. A few times a week
D. Almost every day
7. Have you considered marriage counseling?
A. Yes, and it sounds like a good idea
B. We have mentioned it a couple of times
C. My spouse refuses to attend counseling
D. We have not even discussed it
8. Do you ever feel physically or emotionally abused in your relationship?
A. No
B. Sometimes
C. On many occasions
D. Yes, very much
9. Are you both making efforts to fix your marriage?
A. Yes
B. We are willing to
C. Only I do
D. Not really as we don’t know what to do
10. Do you ever think that you would have been happier outside this marriage?
A. No
B. Only when we have serious fight
C. Yes, sometimes
D. Yes, many times
11. Do you spend time together regularly?
A. Yes, everyday
B. Yes, a few hours at least
C. We have meals together
D. That's rare
12. Do you respect each other’s opinions?
A. Yes, always
B. Mostly
C. Only when we aren't angry
D. Never
13. If you have tried counseling, how effective was it?
A. Very effective
B. Somewhat helpful
C. Made things worse
D. Not applicable because we have not been to counseling
14. How optimistic do you feel about the chances of saving your marriage?
A. Very optimistic
B. Quite optimistic
C. Not very optimistic
D. Not at all optimistic
15. Has your spouse cheated on you?
A. No
B. I don't think so
C. Possibly
D. Yes
