DAS Form

JOY A. DRYER Ph.D

DAS

Zoom and In-person sessions offered.

Name(Required)

First Last

Email(Required)

Sex(Required)

Male

Female

Non-binary

Marital Status(Required)

Age(Required)

Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list.(Required)

	Always agree	Almost always agree	Occasionally disagree	Frequently disagree	Almost always disagree	Always disagree
Handling family finances
Matters of recreation
Religious matters
Demonstrations of affection
Friends
Sex relations
Conventionality (correct or proper behavior)
Philosophy of life
Ways of dealing with parents or in-laws
Aims, goals, and things believed inportant
Amount time spent together
Making major decisions
Household tasks
Leisure time interests and activities
Career decisions

How often?(Required)

	All the time	Most of the time	More often than not	Occasionally	Rarely	Never
How often do you discuss or have you considered divorce, separation, or termination of your relationship?
How often do you or your mate leave the house after a fight?
In general, how often do you think that things between you and your partner are going well?
Do you confide in your mate?
Do you ever regret that you married (or lived together)?
How often do you and your partner quarrel?
How often do you and your mate get on each others nerves?

How often do you kiss(Required)

Intersts(Required)

How often does the following occur between you and your mate?(Required)

There are some things about which couples agree or disagree. Indicate if either item causes differences of opinions or were problems in the past few weeks(Required)

	Yes	No
Being too tired for sex
Not showing love

There aredifferent degrees of happtness on a relationship. The middle point "happy" represents the degree of happiness in most relationships. Choose the phrase which best describes the degree of happiness, all thingsconsidered, of your relationship.(Required)

Which of the following statements best describes how you feel about the future of your relationship?(Required)

I want desperately for my relationship to succeed, and would go to almost any length to see that it does.

I want very much for my relationship to succeed and will do all I can to see that it does

I want very much for my relationship to succeed and will do my fair share to see that it does.

It would be nice if my relationship succeeded, but I can’t do much more than I am doing now to keep the relationship going.

It would be nice if it succeeded, but I refuse to do much more than I am doing now to keep the relationship going.

My relationship can never succeed, and there is no more that I can do to keep the relationship going.

	All of them	Most of them	Some of them	Very few of them	None of them
Do you and your mate engage in outside interests together?

Less than once a month

Once or twice a month

Once or twice a week

Once a day

More often

Have a stimulating exchange of ideas?

Laugh together

Calmly discuss things

Work together on a project

	Every day	Almost every day	Occasionally	Rarely	Never
Do you kiss your mate?