1. Are you afraid of starting a new life?
A. No, but I am sure I don't need one
B. Yes, a lot
C. Yes, a bit
D. No, I am sure I need to start it over
2. Do you feel you’d be better off alone?
A. Not at all
B. I sometimes get this feeling
C. I often think I would
D. Definitely
3. Does your wife meet your physical, emotional, and spiritual needs?
A. Yes
B. Mostly
C. Partly
D. Almost not at all
4. Do you think your children have a bad example in your marriage and may emulate your unhappy relationship?
A. Not the case
B. Possibly
C. Chances are high
D. Definitely
5. Does counseling help improving your relationship?
A. Yes, greatly
B. Yes, to some extent
C. Not really
D. Not at all
6. How are respect and trust in your marriage?
A. Still present
B. Slowly deteriorating
C. Deteriorating at a high pace
D. Completely absent
7. What is the reason keeping you together?
A. Children
B. Financial stability
C. Affection and respect
D. Partnership
8. Are you worried about what your family and friends will think in case you get a divorce?
A. Not at all
B. A bit
C. Moderately
D. A lot
9. Has any of you been unfaithful?
A. Never
B. Just emotionally
C. Once or twice
D. Affairs are something common for us
10. Do you have to put up with abuse from your wife?
A. No
B. Rarely
C. Sometimes, mostly emotional
D. Often, and even physical
