Commitment Questionnaire

This Commitment Questionnaire is not intended to be a diagnostic tool but instead is meant to give you and I a better idea of how you feel about commitment.

Answer the questions below to the best of your ability.

Rate your answers as follows:

(1) Sometimes
(2) Often
(3) Never - or I don't know

1. Incidents in my past make me cautious in my current relationships.

1	2	3

2. Sometimes I find myself preparing for the end of the relationship for no specific reason.

1	2	3

3. I often make commitments to my partner out of a sense of obligation, not because I want to.

1	2	3

4. I feel like I have to be in a relationship in order to appear successful to my family and friends.

1	2	3

5. I often agree to be in a committed relationship (where we only have sex with each other) even though I don't really want to.

1	2	3

6. I am afraid of missing out on other opportunities if I commit to a relationship.

1	2	3

7. I hold back a part of myself in my intimate relationships.

1	2	3

8. I feel comfortable with my level of my commitment in my relationship, but my partner does not.

1	2	3

9. I often wish I wish I was able to be more committed to my partner.

1	2	3

10. When I look back on my past relationship, my partners and I were often out-of-sync about the extent of the commitment in our relationship.

1	2	3

11. I often feel pressured to be more involved in my relationships.

1	2	3

12. I am afraid I might get hurt if I give more of myself to my partner.

1	2	3

13. I feel safe telling my partner about what commitment means to me.

1	2	3

14. My partner and I do not agree about what commitment means in our relationship.

1	2	3

15. I can trust my partner most of the time.

1	2	3

16. I have had difficulty committing in past relationships.

1	2	3

17. I have had partners leave the relationship because I was unable to commit to them.

1	2	3

Congratulations on completing this questionnaire. Enter your contact information below and I will contact you within the next day to discuss your results and find out if you would like to schedule an appointment.

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Dr. Randi Fredricks Ph.D. is a Psychotherapist and licensed as a Marriage Family Therapist MFC 47803. Dr. Fredricks is not licensed with the California Medical
Board or the California Bureau of Naturopathic Medicine. © 2012 Randi Fredricks, Marriage and Family Therapist, Inc. All rights reserved. Serving
San Jose, Sunnyvale, Santa Cruz, Palo Alto, Monte Sereno, Los Gatos, Cupertino, Mountain View, Scotts Valley, Campbell, Willow Glen, and Milpitas CA.