Respect Questionnaire

This Respect 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 respect 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. My partner and I strongly respect each other.

1	2	3

2. When my partner and I have an argument, we never call each other names or yell at each other.

1	2	3

3. Overall, my partner and I are equal in how much influence we have in decisions.

1	2	3

4. Someone has to be the more dominant person in any romantic relationship.

1	2	3

5. I believe that respect relates to the quality of a person's character.

1	2	3

6. Does your partner listen when you say you're not comfortable doing something and then back off right away?

1	2	3

7. I always try to consult with my partner before making decisions that affect him/her.

1	2	3

8. I accept my partner just the way he/she is.

1	2	3

9. If my partner makes a decision concerning his/her own personal matters, and I disagree with it, I am still supportive.

1	2	3

10. My partner and I both rarely use negative labels or call each other names (such as "dumb", "weak", "selfish", or "inconsiderate") even when we are angry with each other.

1	2	3

11. I do not feel very comfortable telling my partner about some things because I am afraid he/she will make me feel bad.

1	2	3

12. I make an effort to consider my partner's feelings whenever we communicate.

1	2	3

13. My partner and I have some goals which are not the same.

1	2	3

14. Our communication is honest, kind, loving and tolerant.

1	2	3

15. We both do things for each other about the same amount of the time.

1	2	3

16. If one of us tries to teach the other how to do something, we frequently have an argument.

1	2	3

17. My partner is always kind to me, no matter how upset he/she may be.

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.