Relationship Communication Pattern & Positive Shift Assessment

A practical self-reflection questionnaire for couples to identify communication damage patterns, existing repair skills, and Head–Heart communication balance. Husband and wife can complete this separately.

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How to Use This Assessment

This tool is designed for couple counselling, premarital counselling, marital counselling and relationship coaching. It is not a diagnosis. It helps the counsellor and couple understand repeated communication habits.

Rating:
0 = Never | 1 = Rarely | 2 = Sometimes | 3 = Often | 4 = Very Often

Important safety note: Privacy is important, but safety is more important. If there is violence, abuse, severe control, threats, addiction risk, self-harm risk, suicidal risk or danger, the person should seek trusted support, professional help, emergency help, legal guidance or safety planning.

Client Details

Name

Date

Filled By

Relationship Status

Assessment Result

Damage Score 0

Positive Shift Score 0

Repair Index 0

Head–Heart Style –

Pie Charts

Damage Pattern Distribution

Positive Shift Distribution

Head–Heart Balance

Pattern-Wise Score Table

Top 3 Counselling Targets

These are the highest damage areas. The matching Positive Shift can become the first counselling focus.

Interpretation Guide

Score Area	Meaning
High Damage + Low Positive Shift	This area needs immediate counselling focus.
High Damage + High Positive Shift	The person has the skill but may not use it consistently during triggers.
Low Damage + Low Positive Shift	The issue may not be active, but preventive skill building is useful.
Low Damage + High Positive Shift	This is a communication strength.

For Couple Counselling Use

Ask both partners to complete this assessment separately. Then compare the scores:

Which damage pattern is highest for each partner?
Which Positive Shift is strongest?
Which Positive Shift is weakest?
Is one partner more emotional and the other more rational?
Which 3 areas should be taken first in counselling?

Suggested counselling direction: First reduce the highest damage pattern, then train the matching Positive Shift, then practise Head–Heart communication.