Updated
Original VAYEMA symptom and impact self-check – not a validated scale
Couples relationship wellbeing
Answer the symptom statements below to see which experiences and areas of daily life you report as most affected. These are original VAYEMA questions, not a validated diagnostic scale. No clinical severity or probability score is calculated.
Answers are processed only in this page by this assessment. They are not submitted, monitored or automatically saved. No name, email or account is required. Use a private device and clear your answers when finished.
For adults aged 18 and over. This self-check cannot diagnose or rule out a condition. Concerns about a child require an age-appropriate professional assessment.
Thinking about the past four weeks, how well does each statement describe your experience?
Additional context – not included in any questionnaire score
These are original VAYEMA questions, not a diagnostic instrument or a validated severity scale. They summarise the experiences you select and do not predict a diagnosis or future harm. Background condition information; this source does not endorse this self-check.
What an assessment should clarify
The first task is to understand the concern in enough detail to choose a suitable next step. A therapist may ask about the relationship’s history, recent changes, recurring difficulties and the effect on each person’s life. They should also establish whether both people want to participate and whether either person feels unable to speak freely. You do not need to arrive with a shared explanation or an agreed plan for the relationship.
An assessment can lead to joint sessions, individual support, another specialist service or a decision not to proceed. Ask what the clinician is assessing and what conclusions they can reasonably draw. A single appointment cannot reliably explain an absent partner’s personality, settle a disputed history or predict whether you will remain together. The useful outcome is a clearer understanding of the options and the reasons behind any recommendation.
Use the worksheet for your perspective, not a verdict
The prompts invite a description of your own experience. They are deliberately unscored because a total would imply a level of precision the questions do not provide. There is no threshold for needing help, and leaving a question blank does not make your concern less important. Avoid turning the notes into a list of charges or a script that the other person must accept before therapy can begin.
You might write that evening conversations often end abruptly and you feel unsure whether the issue will be revisited. That gives the therapist a starting point without deciding why the other person behaves that way. Include what you do in the sequence and what you would like to understand. It is equally acceptable to write only a few words or to prefer speaking in person rather than recording anything on a device.
Prepare one example and its context
Choose a recent interaction that represents the difficulty without being the most overwhelming event to recount. Note the practical circumstances, what was said or done, what you understood and what happened afterwards. Include sleep, work, childcare or other pressures when relevant. The point is not to produce a perfect transcript but to help the clinician see how the situation unfolds in everyday life.
It can also be useful to mention an exception: a time when a similar topic was handled more comfortably. What was different about the timing, expectations or available support? Exceptions may reveal useful resources without proving that the problem is easy to solve. Do not collect messages, recordings or private material from a partner without appropriate consent. An assessment should not require covert monitoring to establish that you deserve support.
Separate goals from demands
Before an appointment, consider what you hope to understand and what you are willing to work on yourself. A goal might be discussing shared responsibilities more clearly or making a considered decision about the future. A demand might be that the therapist persuade your partner to agree with you. The distinction helps protect both people’s agency and gives the therapist a more workable starting point.
You may have different goals, including uncertainty about whether to continue the relationship. State that honestly rather than promising reconciliation to secure an appointment. BACP emphasises voluntary participation when seeking couples therapy. An assessment should therefore allow room for ambivalence, disagreement and a decision not to undertake joint work, without framing those choices as failure.
Ask about private conversations and confidentiality
Before sharing something sensitive, ask how the therapist handles information provided separately. Does the service offer individual assessment conversations? What is the policy on secrets relevant to joint treatment? Who can access records, and how are appointment reminders sent? These questions are especially important when partners share an email account, device, insurance arrangement or payment method.
You can begin by saying that there is something you need to discuss privately, without placing the detail in a general booking message. Ask the professional to explain safeguarding duties and other limits to confidentiality in the relevant setting. No worksheet can provide that explanation for a specific service. Until the arrangements are clear, avoid entering information whose discovery could expose you or another person to harm.
Safety concerns should change the process
Fear of retaliation, threats, coercion, stalking or unwanted sexual pressure are not ordinary disagreements to be scored alongside communication preferences. Tell an appropriate professional through a safe channel and ask for specialist support. Do not complete this worksheet jointly to determine whether abuse is serious enough. You do not need a partner’s permission or a completed assessment before seeking help, and immediate danger needs local emergency services.
Domestic abuse guidance includes considering safe ways for services to contact you. Where a device may be monitored, even neutral-looking notes can carry risk. It may be safer to leave nothing written and speak with a specialist from a safer location or device. Do not confront a partner with assessment answers or announce a safety plan because an online worksheet suggested reflection.
Include individual health and support needs
A relationship assessment should not overlook your own health. You can mention persistent low mood, anxiety, sleep disruption, substance use, pain or recent treatment changes without assuming that these explain every relationship difficulty. Bring a concise account of existing care and ask what is relevant. If medication or physical symptoms need review, that should be addressed by an appropriate healthcare professional.
Think about support outside the relationship as well: friends, family, caring assistance or an existing therapist. A partner should not be your only route to help during a crisis. If several clinicians are involved, ask how information sharing and responsibilities would be agreed. The aim is a coherent plan that respects privacy, not a requirement to disclose your entire individual therapy history in front of someone else.
Practical questions before the first session
Ask about the practitioner’s professional registration, couples-specific training and experience with your concerns. Clarify the session format, length, fees, cancellation arrangements and what contact is available between appointments. You can also ask how the service handles disagreement about payment or attendance. Written practical information can reduce misunderstandings without requiring a detailed personal history at the booking stage.
Consider language, disability access, cultural context, sexual orientation and relationship structure when discussing fit. For online sessions, both people need suitable privacy and a plan for connection problems. BACP describes remote relationship counselling options, but the therapist still needs to assess whether the proposed arrangement is appropriate. Different countries or separate locations may require additional planning.
What to expect from recommendations
At the end of an assessment, ask the clinician to explain their understanding in language you can check and correct. What are the main concerns? What remains uncertain? Why is a particular format recommended, and what alternatives exist? You should know whether further assessment is needed before treatment can begin. It is reasonable to request time to consider the proposal rather than agreeing immediately.
A useful recommendation includes a purpose and a review point. For example, the initial work might focus on recurring conflict while individual health concerns are assessed elsewhere. The NHS describes counselling as helping people explore problems and find their own solutions. The clinician’s role is not to dictate the relationship’s future or promise that a certain number of sessions will produce forgiveness, closeness or reconciliation.
After preparing your notes
Read back only what you feel comfortable keeping. Remove unnecessary identifying details and decide whether you want to bring any notes at all. This tool does not send answers to VAYEMA, alert a clinician or reserve an appointment. An optional downloaded file is an ordinary file on your device; it is not a secure clinical record. Clear the worksheet when finished and consider who has access to downloads or backups.
You can now review the companion treatment page, contact an appropriate professional or pause and return later. Do not interpret completion as evidence that joint therapy is suitable or that the relationship is safe. The assessment conversation remains necessary. Where urgent concerns arise, leave the preparation task and use appropriate local services rather than waiting to finish, print or share your answers.
Frequently asked questions
Does this worksheet produce a relationship score?
No. It is an unscored preparation tool, not a validated compatibility questionnaire or a risk assessment. It does not classify either partner, predict separation or determine treatment. Its only purpose is to help you identify points you may choose to discuss with a professional.
Should both partners complete it together?
Joint completion is not required and may be inappropriate when privacy or safety is uncertain. You can prepare individually, share selected points or use no worksheet at all. Neither partner should demand access to the other’s answers as a condition of attending therapy.
Can I use the assessment when my partner will not attend?
You can use the prompts to prepare for individual support. A clinician can discuss your experience and options but should not claim to assess an absent partner through your notes. The other person’s participation in couples work should remain voluntary, unless a separate legal process applies outside therapy.
Will a therapist keep a separate disclosure secret?
Policies differ, particularly in joint therapy. Ask before sharing sensitive information and request a clear explanation of private conversations, record access and safeguarding limits. Do not assume that a general counselling confidentiality statement answers every question about information shared by one member of a couple.
Do I need evidence that the relationship is difficult?
You do not need a dossier or a completed score to seek help. One example and a description of its effect on you may be enough to begin. Avoid covert recordings or collecting another person’s private information. Safety concerns can be discussed without asking the other person to verify them.
Are my answers monitored or automatically saved?
No answers are sent to VAYEMA or monitored by a clinician through this worksheet. An optional downloaded copy remains on your device and may be accessible to anyone who can access that device. Do not use the tool for urgent help, and avoid writing notes when discovery could increase danger.
Resources and references
[1] BACP: How to seek couples therapy