Assess Trust & Emotional Intimacy in Your Relationship

Help couples explore emotional closeness, trust levels, and communication patterns with this honest and insightful relationship assessment survey.

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Partner Trust & Emotional Intimacy Relationship Assessment Survey

Your Full Name

· · ·

Email Address

· · ·

Age Range

Submit

The Partner Trust & Emotional Intimacy Relationship Assessment Survey is designed to help individuals and couples thoughtfully reflect on the quality of trust, vulnerability, and communication within their relationship. By asking targeted questions about honesty, boundary respect, active listening, and emotional safety, this form provides a structured way to surface important feelings that often go unexpressed.

This template is ideal for relationship coaches, therapists, counselors, and wellness professionals who want to better understand a client's relationship dynamics before a session. It's also a powerful self-reflection tool for individuals looking to gain clarity on their emotional needs and relationship satisfaction. The rating scale and open-ended prompts encourage authentic, nuanced responses beyond simple yes or no answers.

With built-in sections covering demographic background, trust and communication statements, and emotional closeness reflection, this survey covers all the key dimensions of a healthy partnership. Start using this free template today to foster deeper conversations and meaningful insights in relationship support programs.

3 Pages

16 Questions

~5min To complete

Free No credit card needed

Field types Likert Scale ×6 Dropdown ×3 Single Choice ×2 Long Text ×2 Full Name Email Scale Rating

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 About You & Your Relationship 7 questions

Your Background & Relationship Details

1 Your Full Name Full Name

2 Email Address Email

3 Age Range * Dropdown

4 Gender Identity * Single Choice

5 Relationship Status * Dropdown

6 How long have you been in your current relationship? * Dropdown

7 Do you and your partner currently live together? * Single Choice

Page 2 Trust & Communication 7 questions

Assessing Trust & Communication in Your Relationship

Please answer each statement honestly based on how you typically feel in your current relationship. There are no right or wrong answers.

1 I feel confident that my partner is honest with me, even about difficult topics * Likert Scale

2 I trust my partner to keep their promises and commitments * Likert Scale

3 I feel comfortable being vulnerable and sharing my fears or insecurities with my partner * Likert Scale

4 My partner actively listens to me without judgment when I express my feelings * Likert Scale

5 I feel safe bringing up concerns or disagreements without fear of retaliation or dismissal * Likert Scale

6 I believe my partner respects my boundaries and personal space * Likert Scale

7 On a scale of 1–10, how would you rate the overall level of trust in your relationship? * Scale Rating

Page 3 Emotional Intimacy & Reflection 2 questions

Emotional Closeness & Overall Reflection

1 What is one thing you wish your partner understood better about your emotional needs? Long Text

2 Is there anything else you'd like to share about trust or emotional intimacy in your relationship? Long Text

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.