Forms Gottman 17 Area Scale

Name

First Last

Date

Please take the time to read each area below that reflects your life together with your partner. Tell us if this area is fine or needs improvement. Check the boxes that you think applies to your relationship right now. At the end of each area add any comments. If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

1. CONNECTION

Staying emotionally connected
Becoming emotionally distant

Just simply talking to each other.

Not a problem
A problem

Staying emotionally in touch with each other.

Not a problem
A problem

Feeling taken for granted?

Not a problem
A problem

Don't feel my spouse knows me very well right now.

Not a problem
A problem

Spouse is (or I am) emotionally disengaged.

Not a problem
A problem

Spending time together.

Not a problem
A problem

Comments: Connection

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

2. JOB AND OTHER STRESSES

Handling job and other stresses effectively
Experiencing the "spill over" of non-marital stresses

Helping each other reduce daily stresses

Not a problem
A problem

Talking about these stresses together.

Not a problem
A problem

Talking together about stress in a helpful manner.

Not a problem
A problem

Spouse listening with understanding about my stresses and worries.

Not a problem
A problem

Spouse takes job or other stress out on me.

Not a problem
A problem

Spouse takes job or other stresses out on the children or others in our life.

Not a problem
A problem

Comments: Job and other stresses

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

3. ISSUES or DISAGREEMENTS

Handling issues or disagreements well
Gridlocking on one or more issues

Differences have arisen between us that feel very basic.

Not a problem
A problem

These differences seem unresolvable.

Not a problem
A problem

We are living day-to-day with hurts.

Not a problem
A problem

Our positions are getting entrenched.

Not a problem
A problem

It looks like I will never get what I hope for.

Not a problem
A problem

I am very worried that these issues may damage our relationship.

Not a problem
A problem

Comments: Issues or Disagreements

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

4. ROMANCE AND PASSION

The marriage is romantic and passionate.
It is becoming passionless; the fire is going out.

My spouse has stopped being verbally affectionate.

Not a problem
A problem

My spouse expresses love or admiration less frequently.

Not a problem
A problem

We rarely touch each other.

Not a problem
A problem

My spouse (or I) have stopped feeling very romantic.

Not a problem
A problem

We rarely cuddle.

Not a problem
A problem

We have few tender or passionate moments.

Not a problem
A problem

Comments: Romance and Passion

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

5. SEX LIFE

Our sex life is fine.
It is becoming passionless; the fire is going out.

The frequency of sex.

Not a problem
A problem

The satisfaction I (or my spouse) get from sex.

Not a problem
A problem

Being able to talk about sexual problems.

Not a problem
A problem

The two of us wanting different things sexually.

Not a problem
A problem

Problems of desire.

Not a problem
A problem

The amount of love in our lovemaking.

Not a problem
A problem

Comments: Sex Life

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

6. IMPORTANT LIFE EVENT

An important life event (life birth of a child, changes in job, job loss, an illness, death of a loved one) has occurred in our lives.
The marriage is dealing with this well.
The marriage is NOT dealing with this well.

We have very different points of view on how to handle things.

Not a problem
A problem

This event has led my partner to be very distant.

Not a problem
A problem

This event has made us both irritable.

Not a problem
A problem

I'm worried about how this will all turn out.

Not a problem
A problem

We are now taking up very different positions.

Not a problem
A problem

Comments: Important Life Event

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

7. CHILDREN

Major issues about children have arisen.
The marriage is dealing with this well.
The marriage is NOT dealing with this well.

We have very different points of view on goals for the children.

Not a problem
A problem

We have very different positions on what to discipline the children for.

Not a problem
A problem

We have different positions on how to discipline the children.

Not a problem
A problem

We are not talking about these issues very well.

Not a problem
A problem

There is a lot of tension or anger about these differences.

Not a problem
A problem

Comments: Children

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

8. IN-LAW OR RELATIVE(S)

Major issues or events have arisen about in-laws, a relative or relatives
The marriage is dealing with this well.
The marriage is NOT dealing with this well.

I feel unaccepted by my partner's family.

Not a problem
A problem

I sometimes wonder which family my spouse is in.

Not a problem
A problem

I feel unaccepted by my own family.

Not a problem
A problem

There is tension between us about what might happen.

Not a problem
A problem

This issue has generated a lot of irritability.

Not a problem
A problem

I am worried about how this is going to turn out.

Not a problem
A problem

Comments: Issues or Events about in-laws, relative(s)

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

9. EXTRA-MARITAL ATTRACTION

Being attracted to other people or jealousy is not an issue.
Spouse is flirtatious is a problem.
Recent extra-marital affair.

This area is a source of a lot of hurt.

Not a problem
A problem

This area is an area that creates insecurity.

Not a problem
A problem

I can't deal with the lies.

Not a problem
A problem

It is hard to re-establish trust.

Not a problem
A problem

There is a feeling of betrayal.

Not a problem
A problem

It's hard to know how to heal this.

Not a problem
A problem

Comments: Extra-marital attraction/jealousy

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

10. DISAGREEMENTS

When disagreements arise, we resolve issues well.
Unpleasant fights have occurred.

There are more fights now.

Not a problem
A problem

The fights seem to come out of nowhere.

Not a problem
A problem

Anger and irritability has crept in to our marriage.

Not a problem
A problem

We get into muddles where we are hurting each other.

Not a problem
A problem

I don't feel very respected lately.

Not a problem
A problem

I feel criticized.

Not a problem
A problem

Comments: Disagreements

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

11. BASIC VALUES AND GOALS

We are in synchrony on basic values and goals.
Differences between us in these areas or in desired life style are emerging.

Differences have arisen in life goals.

Not a problem
A problem

Differences have arisen about important beliefs.

Not a problem
A problem

Differences have arisen on leisure time interests.

Not a problem
A problem

We seem to be wanting different things out of life.

Not a problem
A problem

We are growing in different directions.

Not a problem
A problem

I don't much like who I am with my partner.

Not a problem
A problem

Comments: Basic values and goals

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

12. HARD EVENTS

Very hard events (for example, violence, drugs, an affair) have occurred within the marriage.
We are handling these well.
They seem to be hard for the marriage to deal with right now.

There has been physical violence between us.

Not a problem
A problem

There is a problem with alcohol or drugs.

Not a problem
A problem

This is turning into a marriage I hadn't bargained for.

Not a problem
A problem

Our marriage "contract" is changing.

Not a problem
A problem

I find some of what my partner wants upsetting or repulsive.

Not a problem
A problem

I am now feeling somewhat disappointed by this marriage.

Not a problem
A problem

Comments: Hard Events

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

13. WORKING AS A TEAM

We work well as a team.
We are not working very well as a team right now.

We used to share more in the family's workload.

Not a problem
A problem

We seem to be pulling in opposite directions.

Not a problem
A problem

Spouse does not share in housework or child care.

Not a problem
A problem

Spouse is not carrying weight financially.

Not a problem
A problem

I feel alone in managing this family.

Not a problem
A problem

Spouse not being very considerate.

Not a problem
A problem

Comments: Working as a Team

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

14. POWER OR INFLUENCE

We are coping well with issues of power or influence.
We are having trouble in this area.

I don't feel influential in decisions we make.

Not a problem
A problem

Spouse has become more domineering.

Not a problem
A problem

I have become more demanding.

Not a problem
A problem

Spouse has become passive.

Not a problem
A problem

Spouse is "spacey", not a strong force in the marriage.

Not a problem
A problem

I am starting to care a lot more about who is running things.

Not a problem
A problem

Comments: Issues of Power or Influence

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

15. FINANCES

We are handling issues of finances well.
We are having trouble in this area.

I, or spouse, just doesn't bring in enough money.

Not a problem
A problem

We have differences about how to spend our money.

Not a problem
A problem

We are stressed about finances.

Not a problem
A problem

Spouse is financially more interested is self than us.

Not a problem
A problem

We are not united in managing our finances.

Not a problem
A problem

There is not enough financial planning.

Not a problem
A problem

Comments: Finances

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

16. HAVING FUN TOGETHER

We are doing well having fun together.
We are not having very much fun together these days.

We don't seem to have very much time for fun.

Not a problem
A problem

We try but don't seem to enjoy our times together very much.

Not a problem
A problem

We are too stressed for fun.

Not a problem
A problem

Work takes up all of our time these days.

Not a problem
A problem

Our interests are so different now that there are no fun things we like to do together.

Not a problem
A problem

We plan fun things to do but they never happen.

Not a problem
A problem

Comments: Having fun together

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

17. SPIRITUALITY

We are feeling close in the area of spirituality together
We are not doing well in that area these days.

Sharing the same beliefs.

Not a problem
A problem

Agreeing about religious ideas and values.

Not a problem
A problem

Issues about specific church, mosque, synagogue, etc..

Not a problem
A problem

Communicating well about spiritual things.

Not a problem
A problem

Issues that are about spiritual growth and change.

Not a problem
A problem

Spiritual issues involving family or children.

Not a problem
A problem

Comments: Spirituality

If things are fine describe how you are managing this area of your life. If things are not fine, describe obstacles you see to improving this area of your relationship

If there is an area we did not cover, please make your comments about that (or anything else) here:

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Gottman 17-Areas Scale