Name *

First Name

Last Name

Date *

MM

DD

YYYY

It’s generally easy to get my partner’s attention *

True

False

I usually come first in my partner’s life *

True

False

I usually feel lonely or shut out in this relationship *

True

False

My partner is mostly there for me *

True

False

I feel I can lean on my partner for support *

True

False

I know my partner cares about me and my feelings *

True

False

I generally feel a strong sense of connection with my partner *

True

False

I express my needs *

Directly

Indirectly

Not at all