Marriage Breakthrough: Relationship Assessment
Please go through the assessment on this page, and thank you for your honesty and for sharing your stories with me!
Marriage Breakthrough Assessment
Complete all 5 sections to help Dr. Smalley understand your relationship
Section 1: Relationship Health Check
Answer these 8 questions honestly to assess the current state of your relationship.
1How often do you and your partner have meaningful conversations?
2When you have a disagreement, how do you typically resolve it?
3How emotionally safe do you feel with your partner?
4How satisfied are you with the level of intimacy in your relationship?
5How often do you feel appreciated by your partner?
6How would you rate your trust in your partner?
7How aligned are you and your partner on major life goals?
8Overall, how hopeful are you about the future of your relationship?
Section 2: Emotional Buttons Discovery
Select your TOP 3 emotional triggers - the feelings that most upset you when activated in your relationship.
Section 3: Core Needs Assessment
Rate how important each need is to you, and how well it's currently being met in your relationship.
1Feeling LOVED and ACCEPTED for who I am
How important is this need to you?
How well is this need being met?
2Feeling RESPECTED and valued
How important is this need to you?
How well is this need being met?
3Feeling HEARD and understood
How important is this need to you?
How well is this need being met?
4Feeling SAFE and secure
How important is this need to you?
How well is this need being met?
5Physical AFFECTION and intimacy
How important is this need to you?
How well is this need being met?
6Quality TIME and attention
How important is this need to you?
How well is this need being met?
Section 4: Conflict Patterns
How do you typically react when you're upset or in conflict with your partner?
1When conflict arises, I tend to shut down or go silent.
2I physically leave the room or house to avoid arguments.
3I avoid bringing up issues that bother me.
4I raise my voice or yell during arguments.
5I bring up past mistakes during current disagreements.
6I use extreme words like "always" or "never" when upset.
7I make excuses or explain why I'm not at fault.
8I counter-attack with my partner's faults when criticized.
9I feel like the victim in most of our conflicts.
10I assume my partner has bad intentions behind their actions.
11I keep mental score of who's done what wrong.
12I believe my partner doesn't care about my feelings.
Section 5: Your Marriage Story
Share your story so Dr. Smalley can better understand your relationship and how to help you.
1How did you and your partner meet? Share your love story.
2What first attracted you to your partner?
3What are the TOP 3 things you love about your partner?
4What are your TOP 3 relationship goals? What do you want your marriage to look like?
5What is the BIGGEST challenge in your relationship right now?
6What patterns do you keep repeating that aren't working?
7What do you and your partner argue about most?
8On a scale of 1-10, how hopeful are you about your relationship?
Why did you choose this number?
9What do you hope to gain from the Marriage Breakthrough Experience?
10Is there anything else Dr. Smalley should know? (Optional)
Your Assessment Results
Here's a summary of your responses. Please enter your information below to send your results to Dr. Smalley.
1. Relationship Health Check
2. Your Top 3 Emotional Buttons
3. Your Top Unmet Needs
4. Your Primary Conflict Pattern
5. Your Story Summary
Send Your Results to Dr. Smalley
✓ Results Sent Successfully!
Thank you for completing the Marriage Breakthrough Assessment.
Dr. Smalley will review your results and be prepared to help you during your session.
Questions?
Email: [email protected]
Phone: (303) 435-2630
