Relationship Feedback Survey Form
Share your honest thoughts to help us understand your relationship experience. Your feedback is valuable and confidential.
How satisfied are you with your relationship overall?
*
1
2
3
4
5
How would you rate communication between you and your partner?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
How much do you feel appreciated by your partner?
*
Not at all
1
2
3
4
Very much
5
1 is Not at all, 5 is Very much
How often do disagreements escalate into arguments?
*
Never
Rarely
Sometimes
Often
Always
How much trust do you feel exists in your relationship?
*
Very little
1
2
3
4
Complete trust
5
1 is Very little, 5 is Complete trust
How well do you and your partner resolve conflicts?
*
Not well
1
2
3
4
Very well
5
1 is Not well, 5 is Very well
How likely are you to recommend relationship counseling or support to others?
Very unlikely
Unlikely
Neutral
Likely
Very likely
What is one thing you appreciate most about your relationship?
What is one area you would like to improve in your relationship?
Please share any additional comments or suggestions.
Submit Feedback
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