(516) 732-0273
Offices in Garden City and Lawrence, NY.

(516) 732-0273

docshulman@yahoo.com

Couples Therapy Readiness Questionnaire:

Couples Therapy Readiness Questionnaire:

Many people who encounter relationship difficulties and consider couples counseling are unsure of whether this process will be beneficial to them. There are numerous providers with various treatment approaches which can make selecting a couples counselor an overwhelming process, particularly during a time of distress. You may wonder how to know who the right couples counselor is for you.

This questionnaire is designed to serve as a guide to help you determine whether couples counseling with Dr. Shulman, utilizing his approach of Complementary Dynamic Experiential Learning (see the My Approach page), can be helpful to you and your partner. The following questions are samples of the types of issues that may be explored during the evaluation process. By answering these questions it may provide you with a window into the treatment process with Dr. Shulman. A customized treatment plan will be developed based on the particular issues involved in your relationship. The length of treatment will vary depending on your particular needs, and will be an ongoing discussion with Dr. Shulman to ensure that your therapy remains productive.

It is important to be aware that the goal of couples therapy will depend on the stage of the relationship. Couples can range from being fully committed to the relationship but wanting assistance with improving the relationship, being unsure of how they want to proceed, being clear that they want to separate, or have already separated but needing help to navigate this process. The common goal of couples counseling in all the relationship stages is to provide clarity for both partners about the relationship, along with strategies to most effectively move in a positive direction.

For each statement check the appropriate response. Please note that not every statement applies to every relationship, please check (N/A) if that statement is not applicable to your relationship.


I want to be in a committed relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I believe that my partner wants to be in a committed relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I feel motivated to work on the issues in our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I believe my partner is motivated to work on the issues in our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I would like to build on the strengths of our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to achieve a higher level of emotional intimacy with my partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to achieve greater sexual satisfaction with my partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to achieve a higher level of relationship satisfaction with my partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I believe that there are enough positive aspects to our relationship that make it worth working through challenges with my partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I believe that my partner and I have the potential to resolve issues effectively with one another with some guidance.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I rely too much on my partner for my happiness and want to learn to be more independent.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I feel that my partner is too dependent on me.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I have difficulty getting close to my partner and want to have a deeper connection with him/her.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I feel that my partner is too distant and want to have a closer relationship with him/her.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to discuss some issues with my partner that I am uncomfortable discussing without a third party facilitating the conversation.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want assistance learning how to resolve a specific area of conflict/concern with my partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I feel that addiction issues (e.g. alcohol, sex, gambling, eating, etc.) are having a significant negative impact on our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want help with addressing a significant challenge that we are facing.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to address a breach of trust that has occurred in our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want to address abuse that has occurred in our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I want assistance determining if my partner and I are compatible with one another.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I am seeking clarity to determine how to proceed with our relationship.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I would like for my partner and me to amicably separate from one another.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


I would like assistance navigating some aspects of the post separation process with my ex-partner.
Strongly Disagree DisagreeNeutralAgreeStrongly Agree(N/A)


If you would like a copy of this questionnaire emailed to you please enter your information below.

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