Research Survey Page
Some of the clinicians at WBH are involved in research. This page will be used periodically to assist us in gathering data about clinical issues. We greatly appreciate your assistance in providing us with information that may help us in our work.
How much would it bother you if you found out your “romantic partner” did the following with an acquaintance of the opposite sex, (or if you are gay, of the same sex). Please click the choice next to each statement that best describes your feelings.
The following survey looks at the issue of what kind of behaviors and activities couples might or might not find acceptable if done by their romantic partner (i.e.that might cause jealousy or conflict). We hope to use this information in our couples therapy to help couples make decisions about what are appropriate relationships to have with others and what aren't. No personally identifiable information is obtained by anyone filling out this form. We thank you for your help!
1. Ran into this person in the supermarket and stopped to chat for a minute-------
2. Made a phone call to this person to discuss work-related issues-------------------
3. Had regular contact (phone, texting, email etc.) with this person about work-related issues -------------------------------------------------------------------------------------
4. Worked with this person on a project for work after business hours---------------
.
5. Made a phone call to this person just to chat--------------------------------------------
6. Had regular contact (phone, texting, email etc.) with this person just to chat---
7. Did not tell you that he/she was having regular contact with this person---------
8. Discussed personal matters about your relationship (such as problems you were having) with this person-------------------------------------------------------------------
9. Went out to eat with this person to discuss work-related issues--------------------
10. Went to this person's home for any reason---------------------------------------------
11. Included this person’s children in activities with your children without your knowledge -----------------------------------------------------------------------------------------
12. Had this person come to your home for any reason without telling you---------
13 Went to this person’s house for any reason -------------------------------------------
14. Went to a work-related social event such as an awards dinner with the this person and not invited you to come as well -----------------------------------------------
15.Travelled for business with this person --------------------------------------------------
16. Travelled for business and not told you that this person was going on the trip
17. Hugged or kissed this person ------------------------------------------------------------
18. Received a gift from this person-----------------------------------------------------------
19. Received a gift from this person and not told you-------------------------------------
20. Allowed this person to give a gift to your children-------------------------------------
21. Went to this person's home and didn't tell you-----------------------------------------
22. Had this person come to your home and didn't tell you-----------------------------
23. Exchanging "flirty" email or text messages or "dirrty jokes" with this person---
24. Seemed to take more care with personal appearance when planning to see this person--------------------------------------------------------------------------------------------
25. Purchased a gift for this person------------------------------------------------------------
26. Purchased a gift for this person and not told you--------------------------------------
27. Preferred to socialize with this person without you being there--------------------
28. Socialized with this person with other people present such as at a
work lunch--------------------------------------------------------------------------------------------
29. Described this person as a "best friend"-------------------------------------------------
30. Discovered your partner was discussing his/her personal issues with this person-------------------------------------------------------------------------------------------------
31. Discovered your partner was using a separate email acccount that your were not aware of to communicate with this person---------------------------------------
32. Lied about any interaction with this person---------------------------------------------
33. Didn't answer phone call from this person in your presence-----------------------
34. Hung up or closed email abruptly when you entered the room--------------------
It would help us to know a little bit about you. Could you tell us:
Age:
Sex:
Thank you again for your help
© 2012 Horan/Dobbins
