The Relationshop

Name *

First Name

Last Name

I know s/he's cheating on me, but s/he won't come clean *

Yes

No

S/he's often critical of me, and puts me down, is emotionally abusive or seems to hold him/herself to a different standard of behavior than me. *

Yes

No

S/he has gotten physical with me during the past 3 months, and I'm afraid it will happen again. *

Yes

No

I feel like I'm walking on eggshells around my partner. *

Yes

No

The people I trust the most think I should get out. *

Yes

No

Lately I feel like I love my partner more than I like my partner. *

Yes

No

S/he admitted to cheating on me, but won't end the affair, or won't come to counseling to deal with it. *

Yes

No

We've tried counseling before, but my partner quit. *

Yes

No

We've tried counseling before, but it didn't seem to make any real difference. *

Yes

No

My partner keeps breaking promises to move things to the next level (living together; getting engaged; etc.) *

Yes

No

I hated being single. I would end things now, but I'm scared of being on my own again. *

Yes

No

Often, work feels like home and home feels like work. *

Yes

No

I knew in my gut I shouldn't have gone out with (or moved in with, or married) him/her. *

Yes

No

There's more pain than pleasure; more bad times than good. *

Yes

No

My partner seems to be addicted to one or more of the following: drugs; alcohol; the internet; video games; porn; gambling; work. *

Yes

No

S/he lies. *

Yes

No

S/he continues to embarrass me in front of others. *

Yes

No

Sometimes I feel s/he's trying to hurt me or push my buttons. *

Yes

No

We're different about closeness: One of us emphasizes "we-ness"; the other emphasizes independence. *

Yes

No