Couples Satisfaction Index Book An Appointment Couples Satisfaction Index Please fill out and be sure to hit the 'submit' button when you are doneName First Last 1. Please indicate the degree of happiness, all things considered, of your relationship. 0 - Extremely Unhappy 1 - Fairly Unhappy 2 - A Little Unhappy 3 - Unhappy 4 - Very Unhappy 5 - Extremely Unhappy 6 - Perfect 2. In general, how often do you think that things between you and your partner are going well? 1 - All the time 2 - Most of the time 3 - More often than not 2 - Occasionally 1 - Rarely 0 - Never 3. Our relationship is strong. 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 4. My relationship with my partner makes me happy. 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 5. I have a warm and comfortable relationship with my partner. 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 6. I really feel like part of a team with my partner. 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 7. How rewarding is your relationship with your partner? 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 8. How well does your partner meet your needs? 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 9. To what extent has your relationship met your original expectations? 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true 10. In general, how satisfied are you with your relationship? 0 - Not at all true 1 - A little true 2 - Somewhat true 3 - Mostly true 4 - Almost Completely true 5 - Completely true For each of the following items, select the answer that best describes how you feel about your relationship. Base your responses on your first impressions and immediate feelings about the item.11. Interesting/Boring 5 - Interesting 4 3 2 1 0 - Boring 12. Bad/Good 0 - Bad 1 2 3 4 5 - Good 13. Full/Empty 5 - Full 4 3 2 1 0 - Empty 14. Sturdy/Fragile 5 - Sturdy 4 3 2 1 0 - Fragile 15. Discouraging/Hopeful 0 - Discouraging 1 2 3 4 5 - Hopeful 16. Enjoyable/Miserable 5 - Enjoyable 4 3 2 1 0 - Miserable Positive Relationship Quality RatingConsidering only the positive qualities of your relationship and IGNORING the negative ones, evaluate your relationship on the following qualities:1. Enjoyable 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 2. Pleasant 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 3. Strong 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 4. Alive 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely Negative Relationship Quality RatingConsidering only the negative qualities of your relationship and IGNORING the positive ones, evaluate your relationship on the following qualities:1. Bad 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 2. Miserable 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 3. Empty 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely 4. Lifeless 0 - Not at all 1 - A tiny bit 2 - A little 3 - Somewhat 4 - Mostly 5 - Very 6 - Extremely Dr. Chris Regan, Psy.D. (310) 870-1275
