BPCS 2.1

1
2
How did you find or hear about this survey?* This field is required.This helps measure the effectiveness of our marketing efforts while keeping this survey free and anonymous.
Search Engines
Social Media
A healthcare professional
A religious professional
A friend or family member
Our website
Other
3
Would you like to complete the optional demographic section?* This field is required.This part of the survey helps us understand unique challenges faced by specific groups of people. And that helps us to make tools that are more useful for each group of people. If you choose, "YES," you will still be able to skip questions.
YESNO
4
Zip Code Where You Live
5
Age
13-15
16-20
21-30
31-40
41-50
51-60
61-70
71-80
80+
Prefer not to disclose
6
Gender
Male
Female
Prefer not to disclose
Other
7
Sexual Orientation
Heterosexual
Homosexual
Bisexual
Prefer not to disclose
Other
8
Education
No formal education
Highschool or GED
Some College or Technical Training
Associate's Degree
Bachelor's Degree
Graduate or Professional Degree
Prefer not to disclose
9
Racial Heritage
White / Caucasian
Black / African American
Asian / Asian American
American Indian or Alaska Native
Chicano / Mexican-American / Hispanic
Native Hawaiian or Other Pacific Islander
Middle-Eastern / Arab / Israeli
Prefer not to disclose
Other
10
Annual Household Income
Less than $15,000
$15,001-$30,000
$30,001-$45,000
$45,001-$60,000
$60,001-$75,000
$75,001-$90,000
$90,001-$120,000
$120,001-$150,000
$150,001+
Prefer not to disclose
11
Which answer best describes why you're taking this survey?* This field is required.
I'm just curious.
I think I have a problem but I'm unsure what it is.
I think I have a specific problem and want to confirm if I'm right.
I know I have a specific problem and want to see if it's better or worse than before.
12
Have you ever been professionally diagnosed with a mental health condition?* This field is required.
YESNO
13
What mental health condition were you diagnosed with?
14
Depression* This field is required.Please indicate how often you feel each of the following emotions?
Never
Rarely
Occasionally
Sometimes
Often
Always
Sad
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Down in the dumps
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Discouraged
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Hopeless
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Inferior
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Worthless
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Unmotivated
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Bored
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Unsatisfied with life
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Suicidal
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Sad
Down in the dumps
Discouraged
Hopeless
Inferior
Worthless
Unmotivated
Bored
Unsatisfied with life
Suicidal
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Occasionally
Row 6, Column 2
Sometimes
Row 6, Column 3
Often
Row 6, Column 4
Always
Row 6, Column 5
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Occasionally
Row 7, Column 2
Sometimes
Row 7, Column 3
Often
Row 7, Column 4
Always
Row 7, Column 5
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Occasionally
Row 8, Column 2
Sometimes
Row 8, Column 3
Often
Row 8, Column 4
Always
Row 8, Column 5
Never
Row 9, Column 0
Rarely
Row 9, Column 1
Occasionally
Row 9, Column 2
Sometimes
Row 9, Column 3
Often
Row 9, Column 4
Always
Row 9, Column 5
1 of 10
15
Depression ScoreScores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
16
Do you have a plan to end your life?* This field is required.
YESNO
17
Suicide RiskIf this number is higher than 2, please call the national suicide prevention hotline at 800-273-8255
18
Anxiety* This field is required.Please indicate how often you feel each of the following emotions. *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
Anxious
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Afraid
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Worried
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Tense
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
On Edge
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Nervous
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Anxious
Afraid
Worried
Tense
On Edge
Nervous
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
1 of 6
19
Anxiety ScoreScores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
20
Anger* This field is required.Please indicate how often you feel each of the following emotions. *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
Frustrated
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Annoyed
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Resentful
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Irritated
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Powerless
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Angry
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Frustrated
Annoyed
Resentful
Irritated
Powerless
Angry
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
1 of 6
21
Anger ScoreScores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
22
Positive Feelings* This field is required.Please indicate how often you feel each of the following emotions. *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
Worthwhile
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Good about yourself
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Close to people
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Motivated
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Calm
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Relaxed
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Loved or loving
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
A sense of belonging
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Encouraged
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Optimistic
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Satisfied with life
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
Worthwhile
Good about yourself
Close to people
Motivated
Calm
Relaxed
Loved or loving
A sense of belonging
Encouraged
Optimistic
Satisfied with life
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Occasionally
Row 6, Column 2
Sometimes
Row 6, Column 3
Often
Row 6, Column 4
Always
Row 6, Column 5
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Occasionally
Row 7, Column 2
Sometimes
Row 7, Column 3
Often
Row 7, Column 4
Always
Row 7, Column 5
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Occasionally
Row 8, Column 2
Sometimes
Row 8, Column 3
Often
Row 8, Column 4
Always
Row 8, Column 5
Never
Row 9, Column 0
Rarely
Row 9, Column 1
Occasionally
Row 9, Column 2
Sometimes
Row 9, Column 3
Often
Row 9, Column 4
Always
Row 9, Column 5
Never
Row 10, Column 0
Rarely
Row 10, Column 1
Occasionally
Row 10, Column 2
Sometimes
Row 10, Column 3
Often
Row 10, Column 4
Always
Row 10, Column 5
1 of 11
23
Positive Feelings ScoreScores between 0 and 2 suggest that therapy may be helpful. Scores higher than 2 indicate that this is a strength.
24
Alcohol and drug use* This field is required.Please indicate how often you think or feel each of the following thoughts or emotions. *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
That you should cut back on your drinking or substance use
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
That others criticize your drinking or substance use
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Guilty about your drinking or substance use
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
That you need to drink or use first thing in the morning, to take the edge off a hangover
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
That you should cut back on your drinking or substance use
That others criticize your drinking or substance use
Guilty about your drinking or substance use
That you need to drink or use first thing in the morning, to take the edge off a hangover
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
1 of 4
25
Frequency CAGE
26
CAGEScores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
27
Problematic Sexual Behavior* This field is required.Please indicate how often you think or feel each of the following thoughts or emotions. *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
How often do you feel preoccupied with sex?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
How often do you hide your sexual behavior from others?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
How many therapists have you seen for sexual behavior or experiences that you did not like?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
How often have others been emotionally hurt by your sexual behavior?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
How often do you feel that your sexual behavior is out of control?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
How often do you feel sad or down after sex?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
How often do you feel preoccupied with sex?
How often do you hide your sexual behavior from others?
How many therapists have you seen for sexual behavior or experiences that you did not like?
How often have others been emotionally hurt by your sexual behavior?
How often do you feel that your sexual behavior is out of control?
How often do you feel sad or down after sex?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
1 of 6
28
Frequency Pathos
29
PATHOSScores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
30
Are you married or in a serious, committed, or living-together relationship?Answering "Yes" will take you to the relationship questions in this survey.
YESNO
31
Safety in your relationship* This field is required.How often do you or your partner... *You may need to scroll down to see the whole table.*
Never
Rarely
Occasionally
Sometimes
Often
Always
Physically hurt each other (hitting, slapping, kicking, etc.)?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Physically intimidate each other (throwing things, slamming doors, blocking a hallway, etc.)?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Threaten each other about leaving or ending the relationship?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Scream at each other?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Physically hurt each other (hitting, slapping, kicking, etc.)?
Physically intimidate each other (throwing things, slamming doors, blocking a hallway, etc.)?
Threaten each other about leaving or ending the relationship?
Scream at each other?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
1 of 4
32
HITS ScaleIf this number is higher than 1.5, please call the Domestic Violence Hotline at 800-799-7233. If this number is between 0 and 2, this suggests elevated conflict in your relationship, and therapy may be helpful.
33
Your perception of your own relationship skills* This field is required.How often do you feel...
Never
Rarely
Occasionally
Sometimes
Often
Always
That you deeply know your partner?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Admiration toward your partner?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Avoidant toward your partner?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Hurt by things your partner may not have meant to be hurtful?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Overwhelmed by the feelings of the moment?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Unable to communicate effectively with your partner?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
That your partner is being completely unreasonable?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
That you cannot trust your partner?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Unsure of your commitment to your partner?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
That you deeply know your partner?
Admiration toward your partner?
Avoidant toward your partner?
Hurt by things your partner may not have meant to be hurtful?
Overwhelmed by the feelings of the moment?
Unable to communicate effectively with your partner?
That your partner is being completely unreasonable?
That you cannot trust your partner?
Unsure of your commitment to your partner?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Occasionally
Row 6, Column 2
Sometimes
Row 6, Column 3
Often
Row 6, Column 4
Always
Row 6, Column 5
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Occasionally
Row 7, Column 2
Sometimes
Row 7, Column 3
Often
Row 7, Column 4
Always
Row 7, Column 5
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Occasionally
Row 8, Column 2
Sometimes
Row 8, Column 3
Often
Row 8, Column 4
Always
Row 8, Column 5
1 of 9
34
How you rated your own relationship skillsScores between 0 and 2 suggest that therapy may be helpful. Scores higher than 2 indicate that this is a strength.
35
Your perception of your partner's relationship skills* This field is required.How often do you feel...
Never
Rarely
Occasionally
Sometimes
Often
Always
Deeply known by your partner?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Admired by your partner?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
That your partner is avoiding you?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
That your partner is hurt by things you did not mean to be hurtful?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
That your partner is overwhelmed by the feelings of the moment?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
That your partner is unable to communicate effectively with you?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
That your partner does not trust you?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Unsure of your partner's commitment to you?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Deeply known by your partner?
Admired by your partner?
That your partner is avoiding you?
That your partner is hurt by things you did not mean to be hurtful?
That your partner is overwhelmed by the feelings of the moment?
That your partner is unable to communicate effectively with you?
That your partner does not trust you?
Unsure of your partner's commitment to you?
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Occasionally
Row 6, Column 2
Sometimes
Row 6, Column 3
Often
Row 6, Column 4
Always
Row 6, Column 5
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Occasionally
Row 7, Column 2
Sometimes
Row 7, Column 3
Often
Row 7, Column 4
Always
Row 7, Column 5
1 of 8
36
How you rated your partner's relationship skillsScores between 0 and 2 suggest that therapy may be helpful. Scores higher than 2 indicate that this is a strength.
37
Relationship Satisfaction* This field is required.How often do you feel satisfied with each of the following areas of your relationship?
Never
Rarely
Occasionally
Sometimes
Often
Always
Communication
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Openness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
How you handle conflict
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Affection
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Closeness
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Intimacy
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Communication
Openness
How you handle conflict
Affection
Closeness
Intimacy
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Occasionally
Row 0, Column 2
Sometimes
Row 0, Column 3
Often
Row 0, Column 4
Always
Row 0, Column 5
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Occasionally
Row 1, Column 2
Sometimes
Row 1, Column 3
Often
Row 1, Column 4
Always
Row 1, Column 5
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Occasionally
Row 2, Column 2
Sometimes
Row 2, Column 3
Often
Row 2, Column 4
Always
Row 2, Column 5
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Occasionally
Row 3, Column 2
Sometimes
Row 3, Column 3
Often
Row 3, Column 4
Always
Row 3, Column 5
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Occasionally
Row 4, Column 2
Sometimes
Row 4, Column 3
Often
Row 4, Column 4
Always
Row 4, Column 5
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Occasionally
Row 5, Column 2
Sometimes
Row 5, Column 3
Often
Row 5, Column 4
Always
Row 5, Column 5
1 of 6
38
Relationship Satisfaction ScaleScores between 0 and 2 suggest that therapy may be helpful. Scores higher than 2 indicate that this is a strength.
39
Mood Related ChallengesThis number considers all the mood scales (depression, anxiety, anger). Scores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
40
Relationship ChallengesThis number considers all the relationship scales (domestic violence, your skills, partner's skills, relationship satisfaction). Scores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
41
Addiction ChallengesThis number scores all the addiction scales (drugs and alcohol, out of control sexual behavior). Scores between 0 and 2 indicate problems within normal ranges. Scores higher than 2 suggest that therapy may be helpful.
42
Before age 18, how often did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
43
Before age 18, how often did you live with anyone who was depressed, mentally ill, or attempted suicide?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
44
Before age 18, how often did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
45
Before age 18, how often did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
46
Before age 18, how often did a parent or adult in your home ever swear at you, insult you, or put you down?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
47
Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
48
Before age 18, how often did you feel that no one in your family loved you or thought you were special?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
49
Before age 18, how often did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?* This field is required.
Never
Rarely
Occasionally
Sometimes
Often
Always
50
Before age 18, did you lose a parent through divorce, abandonment, death, or other reason?* This field is required.
YESNO
51
Before age 18, did you live with anyone who went to jail or prison?* This field is required.
YESNO
52
Would you like to receive an automated follow up course to this survey? This is NOT required, it's totally optional. You can still see your survey results even if you don't want me to keep in touch. The course includes videos about understanding your survey results, my style of therapy, three things to try (customized to your survey responses), and how to get help on any budget.* This field is required.If you select "Yes," you will get 11 emails (one per day), and then I won't bug you any more. I HATE spam. I will NEVER share or sell your contact info.
YESNO
53
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That's it! Now I just have to do some math and load up your survey summary report. This may take a couple of minutes. Is that okay?* This field is required.
61
Frequency ACES
62
ACES
63
Main Problem
64
Main is Mood
65
Main is Addiction
66
Main is Relationships
67
Average of Challenges
68
Average of Strengths
Should be Empty: