Survey

DO NOT PUT YOUR NAME OR DR CASE NUMBER ON THIS SURVEY. 
IT IS FOR STATISTICAL research ANALYSIS ONLY,
AND NOT PART OF ANY COURT RECORD.
THIS IS COMPLETELY CONFIDENTIAL!

Your age:

Under 20 20 - 29 30 - 39 40 - 49 50 - 59 Over 60

Your gender:   

 Male     Female

EDUCATION:

Below 12th Grade   High School Grad or GED
Some College   Tech or Trade School     College Graduate
Graduate school

Combined income before divorce:

Under $30,000    Between $30,000 and $50,000     Over $50,000

Your approximate income after divorce (including any child support):

Under $20,000    $20,000 and $29,000    $30,000 - $39,000
40,000 - $49,000    Over $50,000

Were you gainfully employed during most of your marriage?

Yes    No

Was your spouse gainfully employed during most of your marriage?

Yes    No

ETHNICITY (Choose the ethnicity that best suits you)

Asian    Caucasion    Native American
Black (African American)    Hispanic/Latino    Multi-ethnic
Other

Number of years married

Number of years happy

Number of children involved

Ages of children

How many times have you been married?

Would you consider marrying again? Yes No

Do you want your marriage to end?  Yes No

Does your spouse want the marriage to end?  Yes No

Would you consider a trial reconciliation?  Yes No

Did you have premarital counseling?  Yes No

Did you have sex with your current spouse before marriage?
Yes No

Did you and your spouse live together before you were married?  Yes No

Was your spouse your first sex partner?  Yes No

Have you had marriage counseling?  Yes No

Have you gone through mediation?  Yes No

Can you think of anything that would have prevented the breakup of your marriage?

Do you or your spouse attend any religious service at least once a month?  Yes No

Do your children attend any religious activity at least once a month?  Yes No

Do you think your parents had a happy marriage?  Yes No

Did your parents get divorced? Yes No

If yes, how old were you at the time?

Do you believe your spouse will continue to be involved in your children’s lives?  Yes No

Has your spouse already dropped out of your children’s lives?
Yes No

Where is your spouse?
Same town   Different state   Different country  Incarcerated   Whereabouts unknown

Right now your future looks:  (Check all that apply)
Hopeless   Not good   Good   Great

Right now your children’s future looks:  (Check all that apply)
Hopeless   Not good   Good   Great

Which of these words reflects your feeling about this divorce?
(Check all that apply)
Deep Despair  Regret   Relief  Anger   Disbelief   Shock
Other

How did your children react when they were told about the divorce?  (Check all that apply)
Sadness  Anger   Disbelief   Relief  Too young to understand
Other

Have your children been told it wasn’t their fault?  Yes No 

Have your children tried to get you back together?  Yes No 

Have your children expressed anger towards: (Check all that apply)
Mom   Dad   Others

Did you and your spouse fight over:  (check all that apply)
money
in-laws
your children
children by previous relationships
ex-spouses
alcohol abuse
drug or other substance abuse
spouse couldn’t keep a job
gambling
lying
everything
other

My Spouse was:  (Check all that apply)
Verbally abusive towards me
Verbally abusive towards our kids
Emotionally abusive towards me
Emotionally abusive towards our kids
Physically abusive towards me
Physically abusive towards our kids
Sexually abusive towards me
Sexually abusive towards our kids

I was:  (Check all that apply)
Verbally abusive to my spouse
Verbally abusive towards our kids
Emotionally abusive to my spouse
Emotionally abusive towards our kids
Physically abusive to my spouse
Physically abusive to our kids
Sexually abusive to my spouse
Sexually abusive to our kids

Did the children witness any physical abuse?  Yes No 

Were you verbally abused as a child?  Yes No 

Were you emotionally abused as a child?  Yes No 

Were you physically abused as a child?  Yes No 

Were you sexually abused as a child?  Yes No 

Did your marriage break up for any of these reasons:
(Check all that apply)
Too much conflict in the home
Too much abuse in the home
Communication problems
Not enough time together
Spouse has substance abuse problems
I have substance abuse problems
Didn’t love each other any more
Didn’t like each other any more
Got tired of trying to keep it together
Just didn’t want to be married any more
Spouse fell in love with someone else
I fell in love with someone else
Spouse had sex outside of our marriage with a member of the opposite sex
I had sex outside our marriage with a member of the opposite sex
Spouse had homosexual relationship
I had homosexual relationship
Spouse is having a child with someone else
I am having a child with someone else
We grew in different directions
We wanted different things out of life
Our lives were too boring and predictable
One of us wanted more variety and excitement
I was not truly committed to my spouse or making it work
My spouse was not truly committed to me or making the marriage work
Sickness in the family
Money problems
Child Died
Other

If you had sex outside the marriage,
do any of these reasons explain why: (Check all that apply)
Unresolved anger
Attempt to punish spouse for grievances
Going outside the marriage for comfort, understanding, or appreciation
An attempt to regain youthfulness
A response to neglect
Lack of assertiveness (couldn’t resist temptation)
Attempt to raise one’s self-esteem
An escape from the reality and boredom of every day life
Character weakness
Unmet sexual needs
Other reasons

COMMENTS RELATING TO ANY ASPECT OF MARRIAGE, DIVORCE OR RECONCILIATION: