Marital Intimacy Survey Form
Please complete this survey to help us better understand your experiences and perspectives on marital intimacy. Your responses are confidential and will be used for general relationship assessment purposes only.
What is your current relationship status?
*
Married
In a long-term partnership
Engaged
Other
How long have you been in your current relationship?
*
Please Select
Less than 1 year
1-3 years
4-7 years
8-15 years
More than 15 years
How would you rate your overall satisfaction with intimacy in your relationship?
*
1
2
3
4
5
How frequently do you and your partner engage in intimate connection (physical or emotional)?
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Daily
Several times a week
Once a week
A few times a month
Rarely
Which factors do you feel most influence intimacy in your relationship? (Select all that apply)
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Communication
Time and schedules
Emotional connection
Stress and responsibilities
Health or wellness
Other
How comfortable are you discussing intimacy-related topics with your partner?
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Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Please indicate your agreement with the following statements about your relationship.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel emotionally connected to my partner.
1
2
3
4
5
We communicate openly about our needs.
6
7
8
9
10
We make time for intimacy.
11
12
13
14
15
I feel supported by my partner.
16
17
18
19
20
Are there any barriers that currently impact intimacy in your relationship?
*
Yes
No
If yes, which of the following best describes these barriers?
Busy schedules
Parenting responsibilities
Emotional distance
Stress or anxiety
Health or wellness
Other
What is one goal or hope you have for intimacy in your relationship?
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