Intimacy Questionnaire

This Intimacy Questionnaire is not intended to be a diagnostic tool but instead is meant to give you and I a better idea of the level of romance and intimacy in your relationship.

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. I would like it if my partner and I spent more time talking about how we feel.

1	2	3

2. I often want to say something, but do not because I am afraid how my partner will react.

1	2	3

3. I feel comfortable with my partner most of the time.

1	2	3

4. I can feel vulnerable with my partner.

1	2	3

5. My partner often seems distant.

1	2	3

6. I am comfortable expressing anger with my partner.

1	2	3

7. I am comfortable expressing sadness with my partner.

1	2	3

8. I feel I know and understand who my partner is.

1	2	3

9. We used to share more of our lives with one another than we do now.

1	2	3

10. I always feel safe expressing how I feel with my partner.

1	2	3

11. I feel like I can by myself around my partner.

1	2	3

12. There are specific issues that we have an unspoken agreement not to discuss.

1	2	3

13. I think that my partner knows who I am.

1	2	3

14. My partner knows about the significant events in my life that shaped who I am.

1	2	3

15. My partner knows what causes me to feel stressed.

1	2	3

16. Sometimes I wish I knew my partner better.

1	2	3

17. My partner knows all of my dreams for the future.

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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Telephone:
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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.