Christ-based Counseling Marriage Assessment

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First and Last Name

Enter the Date

YYYY

Please name your assigned counselor (if any)

Section 1 Finance: Define your financial condition

1. We have funds for our bills. We can save money, and have funds for vacation.

2. We have funds for our bills and we can save a little.

3. We'll have enough to make it.

Clear selection

Section 2 Children: What best defines your children situation?

We have no children, or we plan to have one, or our children are on their own.

We have one child or more, or grown step-children on their own.

We have one or more children including step-children at home.

Clear selection

Section 3 Divorce Imprint: Explain whether divorce has been a part of your life.

Neither of us has divorced.

One of us has divorced, or one of our parent's has divorced.

Both of us have been divorced.

Clear selection

Section 4. Educational Differences: Explain the differences in your education

We both have the same level of education (example: both high school, both college grads).

We are one level apart (example: he has a high school diploma, she has college degree (2 or 4 year)

Both are two levels apart (example: she has a high school diploma, he has a graduate degree).

Clear selection

Section 5: Racial Difference: Please explain which is closer to your situation racially/ethnically

We're of the same race.

One spouse is multi-racial including the spouses race.

Both completely different races.

Clear selection

Section 6: Age Difference: Please choose which best fits your situation:

1. Male and female within five years with the male being older.

2. Male and female greater than five, but less than ten years with the male being older.

3. Male and female greater than ten years difference, or female 5 or more years older

Clear selection

Section 7, Sexuality

1. Both spouses have no known physical, mental or spiritual sexual dysfunctions/prohibitions, or diseases

2. One or both had a spouse or sexual-mate previously who complained about sex (too hi or low libido), or one or both experienced some type of sex-related issue.

3. One or both admit having serious issues with sexuality from (early childhood experience, previous spouse, other abuse, religious, etc.).

Clear selection

Section 8: Addictions/Habits

1. No drugs, alcohol, gambling, smoking, porn, hoarding, video gaming, sports, unaccounted absences or other disruptive obsession by either spouse.

2. There is at least one disruptive addiction, habit, or behavior (see above) by one spouse.

3. One or both spouses have more than one of the behaviors or habits cited in (1. Above)

Clear selection

Section 9. Health:

1. Neither spouse has a health issue disruptive to normal life, or requiring medical attention beyond routine check-ups.

2. One or both spouses has/have a significant medical issue requiring special attention and/or periodic hospitalization.

3. One or both spouses have significant medical issues requiring regular hospitalization, daily medical attention and complete spousal involvement daily.

Clear selection

Section 10, Faith:

1. Both spouses are of the same faith and denomination, and their faith activities are very similar.

2. The spouses have a different denomination or church affiliation, or their faith-involvement is demonstratively different.

3. The spouses have completely different religious views, or one has no view at all.

Clear selection

Section 11, Interests:

1. The spouses have two or more interests in their spare time (e.g., sports, crafts, games, vacationing, etc.).

2. The spouses have at least one thing they enjoy doing in their spare time.

3. The spouses have little they enjoy together in their spare time.

Clear selection

Section 12, Communication and Understanding

1. The spouses have no issue openly discussing any of the issues or topics and others in this assessment with each other. And they act as agreed, communicating without (anger, sarcasm, belittling, etc.).

2. One or both spouses do have difficulty openly discussing one or more of the issues in the assessment and does resort to (on occasion) less than healthy speech, or phrases about the other or the relationship.

3. One or both do have difficulty "often" discussing one or more issues in the assessment. It is not unusual that the language is combative, defensive, and usually goes well beyond reaching healthy resolutions.

Clear selection

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