Instructions: For each statement below, rate how true it feels for you on a scale from 0–5:
- 0 = Never
- 1 = Rarely
- 2 = Sometimes
- 3 = Often
- 4 = Almost Always
- 5 = Always
Part 1: Emotional Well-Being
- I feel emotionally drained or anxious after spending time with my partner. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- I feel relieved when I’m apart from my partner. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- I feel safe and comfortable expressing my feelings. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
Part 2: Respect and Trust
- My partner consistently listens to my concerns and validates my feelings. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- I feel respected and valued in this relationship. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- I feel manipulated, belittled, or controlled. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
Part 3: Compatibility and Support
- We share similar core values and life goals. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- My partner and I both make effort to resolve conflicts.
☐0 ☐1 ☐2 ☐3 ☐4 ☐5
- I feel emotionally connected and supported by my partner.
☐0 ☐1 ☐2 ☐3 ☐4 ☐5
Part 4: Motivation and Intention
10.I stay in this relationship because I truly want to, not out of fear, guilt, or
obligation. ☐0 ☐1 ☐2 ☐3 ☐4 ☐5
11.I would feel a sense of relief or freedom if this relationship ended.
☐0 ☐1 ☐2 ☐3 ☐4 ☐5
12.I feel hopeful that our relationship can meet my emotional needs.
☐0 ☐1 ☐2 ☐3 ☐4 ☐5
Scoring Guide
High Scores in Part 1 & 2 (Mostly 4–5s for negative items like feeling drained, manipulated, disrespected): Your emotional well-being may be compromised.
- Low Scores in Part 3 & 4 (Mostly 0–2s for positive items like connection, shared goals, desire to stay): The relationship may not be meeting your needs or may be unsustainable.
- Reflection: Review your highest and lowest scores. Where do you feel stuck, and where do you feel empowered? Use this insight to guide your next steps.
Next Steps
- Journal about patterns or red flags you notice.
- Seek support from a trusted friend, counselor, or support group.
- Consider setting boundaries or creating a plan if leaving the relationship becomes necessary.
