Relationship Inventory
Rate Your Satisfaction in the following areas from 10% to 100 %
Print this document & use the key at the bottom of second page to self-score
1. Commitment __________ %
2. Respect for each other __________ %
3. Intimacy - (sharing, spending time together) __________ %
4. Fidelity __________ %
5. Romance __________ %
6. Fun __________ %
7. Honesty __________ %
8. Affection __________ %
9. Sex __________ %
10. Money __________ %
11. Responsibility - (score self and partner and divide by 2) __________ %
12. Lifestyle Plan __________ %
13. Fighting Fair - (score self and partner and divide by 2) __________ %
14. Communication __________ %
15. Shared Values __________ %
16. Spiritual Growth  __________ %
17. Parenting __________ %
18. Anger Management __________  %

 
Total Scores and Divide by 18

RAW Score of
1440 and over
80-100%
GOOD
RAW Score of
1260 to 1439
70-79.9%
MODERATE
RAW Score of
1080 to 1259
60-69.9%
FAIR
(could use therapy)
RAW Score of
900 to 1079
50-59.9%
POOR
(E-mail)
RAW Score of
0 to 889
0-49.9%
FAILING
( E-mail)

Please feel free to e-mail or call me for an appointment or with any questions

Carole Bergen, Ph.D.

Call (253) 853-5800 for an appointment

Fax: (253) 858-5430
E-mail:  carole@therapy4life.com

Member of   A.A.M.F.T       License # M.F.T. 32512


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