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Gottman Relationship Assessment Form

Review and acknowledge the terms of your treatment plan as part of our commitment to informed care.

Instructions. Please think about how things are RIGHT NOW in each of the following areas of your relationship. Think about each area of your life together, and decide if this area is fine or if it needs improvement. For each of the statements below, check the box that best describes your relationship.

1. Your Emotional Bond
We are staying emotionally connected
becoming emotionally distant

Check all the specific items below:

Just simply talking to each other
Not a problem
Is a problem
Staying emotionally in touch with each other
Not a problem
Is a problem
Feeling taken for granted
Not a problem
Is a problem
Don't feel my partner knows me very well right now
Not a problem
Is a problem
Partner is (or I am) emotionally disengaged
Not a problem
Is a problem
Spending time together is
Not a problem
Is a problem
My emotional attraction toward my partner is
Not a problem
Is a problem
Our current level of physical intimacy is
Not a problem
Is a problem
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