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INSTRUCTIONS: You can answer this questionnaire in English or Filipino.

Answer
as completely as you can. Thank you very much.
Date of Evaluation: _____________________________
Referred by: ___________________________________
References:
Name

Relationship

Contact No.

Your Telephone No.


YOU

YOUR SPOUSE

Name:
Age:
Address:
Date of Marriage:
Place of Marriage:
Date of Separation:
Names and Birthdates of your children:

Background information about YOU:


Date of Birth:
How many brothers?
How many sisters?
Your ordinal position:
About your parents:
Father:
Education and Occupation:
Mother:
Education and Occupation:
1

Describe your parents relationship with each other:

Describe your relationship with your parents and how they treated you:

Describe your relationship with your siblings:

Describe your childhood:

Describe your schooling:

Describe your past relationship with the opposite sex:

Did you experience any crisis in your family? (Ex: vices, mental/ psychological
illness, legal problems, etc.):

Your citizenship:
Your religion:
Your Educational attainment:

Your occupation:
Before marriage:
During marriage:
After separation:
Background information about your SPOUSE:
Date of Birth:
Place of Birth:
How many brothers:
How many sisters:
About his/her parents:
Father:
Education and Occupation:
Mother:
Education and Occupation:

Describe his/her parents relationship with each other:

Describe his/her relationship with his/her parents, how he/she treats them and
how they treat him/her:

Are any of his / her family members with vices? What kind of vices?

What do you know about his/her background?

His/her citizenship:
His/her religion:
His/her educational attainment:
His/her occupation:
Before marriage:
During Marriage:
After Separation:

YOUR COURTSHIP AND MARITAL HISTORY:


How and when did you meet:

Was there a formal courtship? In what manner? How long?

How long have you been steady?

How often did you see each other?

Describe your relationship as sweetheart:

How did you decide to get married?

Who shouldered the expenses during your wedding?

Did you have disappointments during the wedding?

How did you spend your honeymoon? Did you have any frustrations?

Where did you stay after the wedding? List all places where you lived.

What were you means of livelihood during the period of cohabitation?

Complete account of your marital experiences: (Please include your and your
spouses behaviors and attitudes, how you treated each other, your activities
together and why your marriage failed. Cite incidents)

What is your contribution to the failure of your marriage:

How did you separate? Did you have efforts for reconciliation? In whose custody
are the children?

Complete the following sentences. Write the first thing that comes to your mind:
Someday, I want to __________________________________________________.
That worst thing I ever did ____________________________________________.
I believe I have ability to _____________________________________________.
My greatest weakness is _____________________________________________.
I am afraid of ______________________________________________________.
If there is a problem_________________________________________________.
When I was a child, _________________________________________________.

Check the answer of your choices:


1. I am more comfortable
____________being with people

___________alone

2. I believe in my intuition
_____________often

___________rarely

3. In making decision, I rely on my


____________thinking

____________feelings

4.When I want to do something


____________ I do it right away

____________ plan for it