Completed by:     Wife     Husband

How long have you been married?:

I live in the state of 

Age Group:     18-25     26-30     31-40     41-50     50-59     60 over

Number of Times Married:     Once    Twice     Three     More than three

Income:  $0 - 19,999     $20,0000 - $29,999     $30,000 - $39,999     $40,000 - $49,999
                           $50,000 - $74,999     $75,000 - $99,999     $100,000 or more

Number of Children:

We had pre-marital counseling:     Yes     No

How many times do you go on a date with your spouse each month: 0   1   2   3   4  Over 5

What are the top three things you argue about most:

1.

2.

3.

Is romance and sexual intimacy a priority in your marriage:     Yes     No

I want romance and sexual  intimacy to become a priority in my marriage:     Yes    No

How do you rate your romance and sexual intimacy on a scale of 1 to 10 with 1 being boring and 10 being sizzling? 

Would you describe your sexual intimacy as caring, sensitive, loving, and satisfying or quick with little romantic build up or connection? 

What would make your sexual intimacy better? 

Romance and sexual intimacy can be two different things. How would you define romance: 

1.

2.

3.

Overall, I feel honored, valued, and treasured by my spouse:     Yes   No

What makes you feel honored by your spouse?

What makes you feel dishonored by your spouse?

We attend church together at least two times per month:     Yes     No

We pray together:     daily     weekly    seldom     never

We study the Bible together:     daily     weekly     seldom     never

What would make your spiritual intimacy better?

Does your church offer studies to help strengthen marriage on a regular basis:     Yes     No

I rate my marriage as:     Very Satisfied     Satisfied     Unsatisfied

If you answered satisfied or unsatisfied, what would you like to change about your marriage to move it to very satisfied? 

Thanks again for participating!