Santa Monica, Pacific Palisades, Brentwood Relationship Counseling


Please fill out whatever applies to you. This will better assist Dr. Ray in customizing a coaching program for you. Please set up an appointment with him if you choose to discuss this questionnaire directly with him. This is a great easy exercise to get clear with what you would like to get out of working with Dr. Ray.

Current relationship status

In a relationship__ Single __ separated/divorced __

What is the chief complaint about your current relationship?

When and for how long were you in your last relationship?

What do you believe was the primary reason for ending of the relationship?

Do you feel hurt over the relationship?

What emotional phase are you in as far as meeting someone new or improving your current relationship?

A. Hiking alone ____ You have just recently broken up with a lover or still have unfinished business in a past relationship. It might be a time for reflection and healing.

B. Lost traveler ____You are still in contact with your ex-lover while exploring other options. You are still distracted by this person being in your life.

C. Building the family tent ____You are now a newly single mother/father and are making a lot of new adjustments to accommodate the children including figuring out your availability to meet a partner. This includes relocating or possibly a career change.

D. Cub Scout 101____You are going back to school or working on your career. You have very little time to get to know someone. You are still figuring out YOU.

E. Happy but lonely camper____ You might be a workaholic. You have designed a life where all your time is taken and that there is very little drama. You are complacent with your circumstances but fear change and the unknown.

F. One night camper ____You just want to have fun. You might be just looking for sex or nothing too serious.

G. Back packing alone ____You are not necessarily hurt but want to enjoy being single and rediscovering you. You are open to dating but really enjoy the great outdoors by yourself.

H. Campfire crasher ____ You feel desperate and clingy. You might have some codependent tendencies. You are seeking someone to complete you.

I. Campfire songs _____ You are happy with your love but just want to feel more passion, hear more love campfire songs, and bring more spark to the flame.

J. Old sleeping bag ____ You are still with the same person but you know you will never marry him/her. You feel unsatisfied in the relationship.

K. Shinny motor home ____You have done some processing and feel good about yourself. You are fully available and your vehicle is washed, waxed, and running well. You just want a tuned up.