MARITAL FORM Please print one for each person.

About Me     Welcome Letter     Confidentiality Form     Intake Form

Please print and fill out forms. Return to Dr. Ruth Parvin 2925 S.E. Taylor Portland, OR 97214

Name Date

RESPONSES TO CONFLICT

Please indicate if you and your partner/spouse use any of the following behaviors when having conflicts. Check the appropriate box on the scale to indicate how often, if ever, these behaviors occur in the process of dealing with the problem.

Behaviors Yourself Your Partner Never >>> Most of Time Never >>> Most of Time Hitting, biting, or scratching Yelling or screaming Swearing Nagging Complaining Using sarcasm (put-downs) Critizing unfairly Sulking Ignoring (using a silent treatment) Refusing to talk about problem Leaving the scene Crying Drinking or using drugs Bringing up other issues or sidetracking discussion Trying to be sexual when other is not interested Becoming jealous Other_______________ How did your parents handle problems when they arose in their relationship?       If you have been in a long term relationship previous to this one, how did your partner handle his/her anger?       What changes would you like to see in the way you and your partner handle emotional issues?       What personal changes are you trying or wanting to make?       If you meet your goals in counseling, how will your relationship be different?