• Gay Couples Institute Assessment

    Please allow about 1 hour to complete the assessment.

    Before you start completing this assessment, please do the following to ensure all your information is captured correctly, especially if you cannot complete it in one sitting and want to come back to it later:

    Step 1: Sign up for a free Jotform account by clicking 'Save My Work' (at the bottom of this page). Then, 'Sign Up with Email'.


    Step 2: Use a desktop computer, not your mobile phone.


    Step 3: Delete your Jotform account or unsubscribe from the JotForm emails once you've completed and submitted all the assessment pages.

    Need to come back later? If you want to complete the assessment at a later time, click 'Save My Work' to 'Sign Up with Email' to create an account now. This will ensure you don't lose all of the progress you have made up until this point.

     

    Wishing you success and happiness,
    Sam & Alapaki

     

    PS, if you have questions, contact us at admin@gaycouplesinstitute.org.

  • Please click 'Save My Work' (at the bottom of this page) and 'Sign Up with Email' to create a new free account before you continue.

    Click 'Next Page' below to advance to the rest of the assessment.

  • Note: All information provided will be used for internal purposes only and will be treated with the highest confidentiality.

  • Gay Couples Institute Assessment

    Please answer honestly to the best of your ability, and don't overthink the questions on this page.

    This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you.

    If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.

    NOTE: Please allow 45-60 minutes to complete this assessment.

    Note: If you want to complete your assessment later, click Save for later, and Sign up with Email to create a new free account. If you don't create a new account, you will lose your progress so far. Enter your email address, and you will get your uncompleted assessment link in your inbox.

    Avoid filling the survey on mobile devices.

  • Gay Couples Institute Assessment

    Please answer honestly and don't overthink the questions on this page. This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you. If you find some of the questions difficult, please give the answer that is true for you in general or most of the time

  • DEMOGRAPHIC INFORMATION SHEET

    Please supply the information requested below.  We realize that some of this information is very personal and sensitive, and we are asking you to trust us and report honestly.  All information will be kept completely confidential.  This demographic information sheet applies to you as an individual, not as a couple.



  • Couple Adjustment Test

    Check the dot on the scale line below which best describes the degree of happiness, everything considered, of your present relationship.  The middle point “happy” represents the degree of happiness which most people get from a relationship, and the scale gradually ranges on one side to those few who are very unhappy in relationship, and on the other, to those few who experience extreme joy or felicity in the relationship.

  • State the approximate extent of agreement or disagreement between you and your partner on the following items.

  • Please select one for each:

  • Please click Submit to send your completed assessment to our clinical team. (Please do not refresh the page).

    Click Next Page below and continue to the next page.

  • Note: If you want to complete your assessment later and save your progress so far, please click Save My Work, and Sign up with Email to create a new free account. If you don't create a new account, you will lose your progress so far. Check your inbox for a link to your uncompleted assessment.

  • Your Personal Resilience

     Please answer honestly and don't overthink the questions on this page.

    This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you.

    If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.

  • Your Personal Resilience

    Please answer honestly and don't overthink the questions on this page. This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you. If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.
  •  
  •  
  •  
  •  

  • Your Personal Happiness

    Take time to reflect and complete each item on the survey below. There are no right answers.
  •  

  • Please click Submit to send your completed assessment to our clinical team. (Please do not refresh the page).

    Click Next Page below and continue to the next page.

     

  • Note: If you want to complete your assessment later and save your progress so far, please click Save My Work, and Sign up with Email to create a new free account. If you don't create a new account, you will lose your progress so far. Check your inbox for a link to your uncompleted assessment.

  • Please answer honestly and don't overthink the questions on this page.

    This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you.

    If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.

  • We have learned that the following questions help quickly identify how your relationship is doing. The questions might seem random, but most couples find that these questions make them think about their relationship in a new way. Please trust the process and try to answer to the best of your ability. You will find this really helps to speed up your progress with us.

  • 1. LOVE MAPS

    Read each statement and select TRUE or FALSE.

  • 2. FONDNESS AND ADMIRATION SYSTEM

    Read each statement and select TRUE or FALSE

  • 3. TURNING TOWARD OR AWAY

    Read each statement and select TRUE or FALSE.

  • 4. EMOTIONAL DISENGAGEMENT AND LONELINESS

    Read each statement and select TRUE or FALSE.

  • 5. HARSH STARTUP

    Read each statement and select TRUE or FALSE.

  • When we discuss our issues:

  • 6. THE FOUR HORSEMEN

    Read each statement and select TRUE or FALSE.

  • When we discuss our issues:

  • 7. GRIDLOCK ON PERPETUAL ISSUES

    Read each statement and select TRUE or FALSE.

  • When we discuss our issues:

  • 8. ACCEPTING INFLUENCE

    Read each statement and select TRUE or FALSE.

  • When we discuss our issues:

  • 9. COMPROMISE

    Read each statement and select TRUE or FALSE.

  • During our attempts to resolve conflict between us:

  • 9b. FLOODING

    Read each statement and select TRUE or FALSE. We want you to think about how well you and your partner have been able to handle physiological and physical overwhelm when you're having conflict.

  • 10. Shared Meanings Questionnaire Honoring Each Others Dreams: rituals

    We want you to think about how well you and your partner have been able to create a sense of shared meaning in your lives together. We think that when people become committed to one another they create a new culture, and some relationships also involve the union of two very different cultures. But even if two people are coming from the same regional, cultural, ethnic, and religious background, they will have been raised in two very different families, and their merging involves the creation of a new culture.

  • 11. Shared Meanings Questionnaire Honoring Each Others Dreams: Roles

  • 12. Shared Meanings Questionnaire Honoring Each Others Dreams: Goals

  • 13. Shared Meanings Questionnaire Honoring Each Others Dreams: Symbols

  • 14. NEGATIVE SENTIMENT OVERRIDE

    Fill this form out thinking about your immediate past (last 2 to 4 weeks), or a recent discussion of an existing issue. Read each statement and select TRUE or FALSE.

  • In the recent past discussing our issues generally:

  • 15. EFFECTIVE REPAIR ATTEMPTS

    Read each statement and select TRUE or FALSE.

  • During our attempts to resolve conflict between us:

  • Please click Submit to send your completed assessment to our clinical team. (Please do not refresh the page).

    Click Next Page below and continue to the next page.

     

  • Note: If you want to complete your assessment later and save your progress so far, please click Save My Work, and Sign up with Email to create a new free account. If you don't create a new account, you will lose your progress so far. Check your inbox for a link to your uncompleted assessment.

  • The Gottman 19 Areas Checklist for Solvable and Perpetual Problems

    Please answer honestly and don't overthink the questions on this page.

    This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you.

    If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.

     

    Instructions.

    1. Please think about how things are RIGHT NOW in each of the following areas of your relationship.
    2. Think about each area of your life together, and decide if this area is fine or if it needs improvement.
    3. For each of the statements below, check the box that best describes your relationship.

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Answer all the specific items below:

  •  

  • Please click Submit to send your completed assessment to our clinical team. (Please do not refresh the page).

    Click Next Page below and continue to the next page.

  • Note: If you want to complete your assessment later and save your progress so far, please click Save My Work, and Sign up with Email to create a new free account. If you don't create a new account, you will lose your progress so far. Check your inbox for a link to your uncompleted assessment.

  • Please answer honestly and don't overthink the questions on this page.

    This is not a test, and there are no 'right' or 'wrong' answers and no trick questions. The first answer that comes into your head is probably the right one for you.

    If you find some of the questions difficult, please give the answer that is true for you in general or most of the time.

    This is the LAST part of the assessment. It is rather short, compared to the part you’ve already completed. You can come back to it later if you like. It asks a lot of personal information, which is all confidential.

    Your clinician will receive your results and use them to help this process continue moving quickly.

    This portion should take you about 20 minutes….

  •  

  • SUICIDE POTENTIAL

  • Does the following describe you at the moment?

  • Does the following describe you at the moment?

     

  • Relationship Behaviors - Please indicate how often each of the items happened in the past 6 months:

  • Fear of Partner as a potential result of Therapy

  • DRUG AND ALCOHOL SCREENING TEST

    What we mean by the term “drugs”: Opiates (for example, morphine, codeine, heroin), Depressants (for example, barbiturates), Stimulants (for example, cocaine, amphetamines), Hallucinogens (for example, LSD, Mescaline), Marijuana, Hashish, other illegal substances (for example, Psilocybin, DMT, DET, PCE, PCP, TCP)

    Please respond to each item for yourself and your partner:
    * You
    * Partner

  •  
  •  
  •  
  •  

  • 1. CHAOS Instructions. Select True or False for each item below.

  •  

  • 2. TRUST

    Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either Strongly Disagree, Disagree, Neither agree nor disagree, Agree, Strongly Agree.

    This section is easily done on a keyboard by selecting "TAB" to move between items, and "S", "D", "N, "A", or "SS"...

  •  

  • 3. COMMITMENT

    Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either SD for Strongly Disagree, D for Disagree, N for Neither agree nor disagree, A for Agree, and SA for Strongly Agree.

    This section is easily done on a keyboard by selecting "TAB" to move between items, and "S", "D", "N, "A", or "SS"...

  •  

  • 4. YOUR OWN FEELINGS ABOUT EMOTIONS (META-EMOTIONS) What’s your emotion philosophy?

    Instructions. For the following items answer the degree to which you agree or disagree with each item by selecting either SD for Strongly Disagree, D for Disagree, N for Neither agree nor disagree, A for Agree, and SA for Strongly Agree.

    This section is easily done on a keyboard by selecting "TAB" to move between items, and "S", "D", "N, "A", or "SS"...

  •  

  • Please click Submit to send your completed assessment to our clinical team. (Please do not refresh the page).

     

  • It may take a few moments to submit.
    Please do not refresh the page.

     

    Once you have pressed submit on this page, and you've created a free account, you're finished!

    Thank you for your responses, and helping us make good use of your time by quickly identifying the next steps you can take to improve the situation.

    We'll have personalized feedback at our next meeting.

    Any questions, please find us admin@gaycouplesinstitute.org

    Wishing you success and happiness, 
    Sam, Alapaki, and the GCI Team :) 

  • Should be Empty: