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Relationship Evaluation Form
A person's personal and professional relationships can have a significant impact on their stress and anxiety level, and be major triggering factors of their symptoms. Because of this it is important for you to evaluate the main relationships in your life at this time. This process will help you ascertain what, if any, relationships are causing you stress and contributing to your symptoms. Also, this evaluation will help you to begin to think of ways to address these issues and adjust these relationships as needed. Do not feel like you have to complete this list at one time. You will be asked to add to this list throughout the program. As you work through the program, if you think of a relationship that needs to be added to this list, add it. This form contains spots for five relationships, if you need to add more feel free to. The form is pretty straightforward.
Name____________________________________ Type of Relationship_________________________________
Nature of Relationship (positive or negative)______________________________________________________
Affect on Your Health___________________________________________________________________________
______________________________________________________________________________________________
How will this relationship affect your treatment_____________________________________________________
______________________________________________________________________________________________
What will you do about this relationship____________________________________________________________
______________________________________________________________________________________________
Name____________________________________ Type of Relationship__________________________________
Nature of Relationship (positive or negative)_______________________________________________________
Affect on Your Health___________________________________________________________________________
______________________________________________________________________________________________
How will this relationship affect your treatment_____________________________________________________
______________________________________________________________________________________________
What will you do about this relationship____________________________________________________________
______________________________________________________________________________________________
Name____________________________________ Type of Relationship__________________________________
Nature of Relationship (positive or negative)_______________________________________________________
Affect on Your Health___________________________________________________________________________
______________________________________________________________________________________________
How will this relationship affect your treatment_____________________________________________________
______________________________________________________________________________________________
What will you do about this relationship____________________________________________________________
______________________________________________________________________________________________
Name____________________________________ Type of Relationship__________________________________
Nature of Relationship (positive or negative)_______________________________________________________
Affect on Your Health___________________________________________________________________________
______________________________________________________________________________________________
How will this relationship affect your treatment_____________________________________________________
______________________________________________________________________________________________
What will you do about this relationship____________________________________________________________
______________________________________________________________________________________________
Name____________________________________ Type of Relationship__________________________________
Nature of Relationship (positive or negative)_______________________________________________________
Affect on Your Health___________________________________________________________________________
______________________________________________________________________________________________
How will this relationship affect your treatment_____________________________________________________
______________________________________________________________________________________________
What will you do about this relationship____________________________________________________________
______________________________________________________________________________________________
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