Life Management Associates, LLC
600 Dewey Blvd., Suite B Office: 406-782-4778
Butte, MT 59701 Fax: 406-782-1318
EFT COUPLES QUESTIONNAIRE
L IFE M ANAGEMENT A SSOCIATES, LLC
LMA EFT COUPLES QUESTIONNAIRE
Name_________________________________________________________Age_____________
Relationship Status________________________ Years together__________________________
Please answer each question as completely an accurately as possible. Your information will help me
learn about your relationship and help me plan your treatment. If you are faxing it, my confidential
fax is 406-782-1318. If you are emailing it, send it to: [email protected].
1. What are the things you like most about your relationship?
2. What do you like most about your partner?
3. What are the things you most want to change?
600 Dewey Blvd., Suite B, • Butte, MT 59701 & 302 Missouri Ave., • Deer Lodge, MT 59722
Phone: 406-782-4778 • Fax: 406-782-1318
Navigating Life's Obstacles…….Choose LMA
L IFE M ANAGEMENT A SSOCIATES, LLC
LMA EFT COUPLES QUESTIONNAIRE
4. How often do you argue? What do you most often argue about?
5. Describe in detail your most recent argument. How did it start? How did it end?
6. When you argue, does someone end up leaving? Who? How long before they come back? How
long do you stay angry at each other?
7. Who is the first to attempt to make things better?
8. Do your arguments get physical? Verbally abusive? Please detail.
600 Dewey Blvd., Suite B, • Butte, MT 59701 & 302 Missouri Ave., • Deer Lodge, MT 59722
Phone: 406-782-4778 • Fax: 406-782-1318
Navigating Life's Obstacles…….Choose LMA
L IFE M ANAGEMENT A SSOCIATES, LLC
LMA EFT COUPLES QUESTIONNAIRE
9. Who initiates sex most often?
10. If you are not having sex, when and how did it stop?
11. Do you use sex to repair the relationship? How?
12. Is sex a painful topic in your relationship? Why?
13. Do you feel safe and secure with your partner? Now? In the past? Please detail.
600 Dewey Blvd., Suite B, • Butte, MT 59701 & 302 Missouri Ave., • Deer Lodge, MT 59722
Phone: 406-782-4778 • Fax: 406-782-1318
Navigating Life's Obstacles…….Choose LMA
L IFE M ANAGEMENT A SSOCIATES, LLC
LMA EFT COUPLES QUESTIONNAIRE
14. In your present relationship, can you ask your partner when you need closeness and comfort?
Please detail. Can you rate your level of difficulty (1 extremely easy --– 10 extremely difficult).
15. Can you think of bonding moments in your relationship when one of you reaches out and the other
responds in a way that makes you both feel emotionally connected and secure with each other? Please
detail.
16. What messages about love/marriage did you get from your parents? Your community?
17. Before your present relationship, did you experience a safe, loving relationship with someone you
trusted, felt close to and could turn to if needed? Who? Please detail.
18. Are there significant times in your present relationship that you felt your partner was not there for
you. Please detail.
600 Dewey Blvd., Suite B, • Butte, MT 59701 & 302 Missouri Ave., • Deer Lodge, MT 59722
Phone: 406-782-4778 • Fax: 406-782-1318
Navigating Life's Obstacles…….Choose LMA
L IFE M ANAGEMENT A SSOCIATES, LLC
LMA EFT COUPLES QUESTIONNAIRE
19. If it is hard for you to turn to and trust others, to let them close when you really need them, what do
you do when life gets too big to handle or when you feel alone?
20. Name two specific things that would make you feel safer and more secure in your present
relationship.
Anything else about your relationship you wish to share?
Client signature____________________________________________________ Date____________
Notes:
600 Dewey Blvd., Suite B, • Butte, MT 59701 & 302 Missouri Ave., • Deer Lodge, MT 59722
Phone: 406-782-4778 • Fax: 406-782-1318
Navigating Life's Obstacles…….Choose LMA
