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GEMA™-Couples360 - Couples Assessmsent          

 

Response Form for the "Self" and "Other" Assessment

Instructions:   FIRST, GET YOUR CODE NAMES

FROM THE ADMINISTRATOR AT:

Email: DrDavid@LifePsych.com

  • GEMA™-Couples360 (Couples Assessment) is a "360 Degree" assessment instrument useful for assessing the behavioral qualities of relationship interactions.
  • This form is designed to assess and evaluate relationship behavior.
  • If this is a Self-assessment, you must answer all the items and it is helpful to be as honest with yourself as you can.
  • If you are assessing an "Other," you must answer all the items and be as behaviorally accurate as possible, given your experience with the "Other". Your honest behavioral assessment of your "Self" and the "Other" will be the most helpful for couples coaching and relationship development. Your responses should evaluate relationship behavioral patterns noted in recent months.
  • Incomplete response forms will be indentified. If some responses have been omitted, you will be asked to use your browser's "BACK" button to return to the form, find your missing responses and re-submit.
Person being evaluated Code Name:

Evaluating person

Code Name:

Note:
          Only GEMA™-Couples360 scoring professionals will have access to code names. If you have any questions or doubts about the confidential status of your responses, please make sure you clarify this issue with your administrator before responding.


You must respond to all items.

Section 1: Please make use of the entire five-point scale in responding
1. Invests energy in promoting a meaningful relationship.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
2. Avoids expression of thoughts and ideas to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
3. Tells the truth.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
4. Controls for the purpose of demonstrating power over the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
5. Tries to intimidate the other with expressions of excessive self-importance.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
6. Speaks well of the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
7. Actually helps the other to achieve full potential.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
8. Becomes more tense when pressures increase.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
9. Seeks out ways to affirm the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
10. Actually makes useful contributions to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
11.  Maneuvers the other by expressing self-serving needs.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
12.  Works toward helping the other do better.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
13.  Responds constructively toward ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
14.  Remains relatively "happy as ever" when serious difficulties arise.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
15.  Puts self-centered interests ahead of the relationship.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
16.  Seems hesitant to express thoughts and ideas to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
17.  Makes earnest efforts to nurture the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
18. Shows little energy for ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
19.  Masterfully leads the relationship into a positive future.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
20.  Works on own individual growth.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
21.  Acts as if "all knowing" or "all powerful" toward the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
22.  Leads the other in creating mutual relationship benefit.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
23.  Resists cooperating with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
24.  Tries to be a ruler over the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
25.  Behaviorally treats the other as an equal.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
26.  Is stubborn and inflexible with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
27.  Assertively expresses thoughts and ideas to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
28.  Participates in making useful contributions to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
29.  Would rather be successful than fail.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
30.  Dictates relationship activities with a superior attitude.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
31.  Is affirming and supportive of the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
32.  Acts as if unfeeling for the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
33.  Is respectfully persuasive toward the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
34.  Would rather fail than succeed.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
35.  Is moody and crabby toward the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
36.  Initiates constructive responses toward ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
37.  Intentionally works against the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
38.  Effectively guides the other toward mutual relationship benefit.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
39.  Appears to have little energy for ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
40.  Creates activity that promotes a meaningful relationship.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
41.  Gets even; is quick to retaliate toward the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
42.  Expresses positive energy toward ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
43.  Seems aloof from ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
44.  Makes a special effort to invest time and energy in the relationship.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
45.  Seeks out ways to affirm the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
46.  Has a positive attitude toward ordinary relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
47.  Expects favors from the other but does not return favors.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
48.  Tends to express thoughts and ideas to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
49.  Appears to understand the importance of nurturing the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
50.  Seems heartless for the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
51.  Brags about own achievements as being superior to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
52.  Initiates friendly interactions with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
53.  Is a positive example for treating the other as an equal.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
54.  Strives to respectfully persuade the other regarding joint activities.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
55.  Avoids interacting with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
56.  Appears to resist cooperating with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
57.  Makes efforts to respond to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
58.  Expects special treatment from the other without providing the same.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
59.  Masterfully expresses positive visions for a meaningful relationship with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
60.  Has thoughts and feelings.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
61.  Avoids routine relationship interactions.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
62.  Consistently responds to the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
63.  Manipulates the other for own self-serving advantage.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
64.  Is consistently involved with the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
65.  Is disconnected from the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
66.  Tries to control the other with the use of criticism.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
67.  Creates special privileges for self at the expense of the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
68.  Invests in relationship efforts beyond own self-interest.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
69.  Tends to be critical of the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
70.  Is arrogant toward the other.
Never, Almost Never
Seldom
Sometimes
Often
Always, Almost Always
71.  Have you responded honestly and accurately?
Yes
Mostly Yes
Mostly No
No
 

Please read the following brief descriptions of some relationship behaviors:

  Cooperative: Cooperates with the other as an equal.
  Withdrawing: Is detached from the other.
  Entitled: Expects special consideration from the other.
  Connecting: Communicates and listens to the other.
  Dominating: Attempts to control or dominate the other.
  Contributing: Leads the other in positive directions.

With your "self" or the "other's" behavior in mind, please respond to the following paired-comparisions by selecting the word (or words) that best describes "you" or "the other."       If both descriptions apply equally, respond "Both apply equally". If neither description applies at all, respond "Neither applies at all." Only one response per item is allowed and please respond to all of the items. 
 
Depending upon the perspective (self or other) of this administration, which response best applies to the "self" or "other's" behavior:

1. Withdrawing
Connecting
Both apply equally
Neither applies at all
 
2. Dominating
Contributing
Both apply equally
Neither applies at all
 
3. Cooperating
Connecting
Both apply equally
Neither applies at all
 
4. Dominating
Entitled
Both apply equally
Neither applies at all
 
5. Contributing
Cooperating
Both apply equally
Neither applies at all
 
6. Connecting
Dominating
Both apply equally
Neither applies at all
 
7. Entitled
Withdrawing
Both apply equally
Neither applies at all
 
8. Connecting
Contributing
Both apply equally
Neither applies at all
 
9. Entitled
Cooperating
Both apply equally
Neither applies at all
 
10. Contributing
Withdrawing
Both apply equally
Neither applies at all
 
11. Cooperating
Dominating
Both apply equally
Neither applies at all
 
12. Entitled
Connecting
Both apply equally
Neither applies at all
 
13. Dominating
Withdrawing
Both apply equally
Neither applies at all
 
14. Contributing
Entitled
Both apply equally
Neither applies at all
 
15. Withdrawing
Cooperating
Both apply equally
Neither applies at all
     

           Narrative comments are very helpful, but not required.

Narrative Compliments and Suggestions.
Constructive compliments and suggestions may be useful to determine the best areas for focus.  

Note: Do not use the "enter" key when filling out narrative comments

as that will prematurely submit the results.

What are some especially positive and useful relationship characteristics of youself or the other?
1.
2.
3.
4.
5.
What are some areas that would help you or the other become more effective in the relationship?
1.
2.
3.
4.
5.
General Comments regarding this assessment that might be used to improve the quality of the items:



Goal Evaluation and Matrix Analysis - Leadership Development (GEMA™-Lead360) along with the Couples Assessment (GEMA™-Couples360) and all related materials are a Registered © Copyright 1990,'91,'92,'93,'95,'98,'02,'09 of David L. Hanson, Ph.D. with All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission in writing from the publisher.

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Registered © Copyright 1990,'91,'92,'93,'95,'98,'02,'09
David L. Hanson, Ph.D. All Rights Reserved. Synergistic Psychology Associates, P.A.