In order to get an idea of how your marriage stands right now please answer the following questions by
      checking TRUE or FALSE of each item.

_____ _____ 1. I have not made any specific plans to discuss separation or divorce with my
                            spouse. I have not considered what I would say, etc.. (True means that you have
                            not done so.)

_____ _____ 2. I have set up an independent bank account in my name as a measure of protecting
                             my own interests.

_____ _____ 3. Thoughts of divorce occur to me frequently, as often as once a week or more.

_____ _____ 4. I have not suggested to my spouse that I wished to be divorced, separated, or rid
                              of him/her. ( False if you have suggested.)

_____ _____ 5. I have thought specifically about divorce or separation; I have considered who
                             would get the kids, how things would be divided, pros and cons of such actions, etc.

_____ _____ 6. My spouse and I have separated. [This is (a) a trial separation or (b) a permanent
                             separation; (check one)]

_____ _____ 7. I have discussed the question of my divorce or separation with someone other than
                             my spouse (trusted friend, psychologist, minister, etc.).

_____ _____ 8. I have occasionally thought of divorce or wished that we were separated, usually
                            after an argument or other incident.

_____ _____ 9. I have not discussed the issue seriously or at length with my spouse. (False means
                             that you HAVE discussed.)

_____ _____ 10. I have filed for divorce or we are divorced.

_____ _____ 11. I have made no inquiries from nonprofessionals as to how long it takes to get a
                               divorce, grounds for divorce, costs involved in such action, etc.
                             (False means you have made inquiries.)

_____ _____ 12. I have not contact a lawyer to make preliminary plans for a divorce. (False means
                               that you have consulted, etc.)

_____ _____ 13. I have not consulted a lawyer or other legal aid about the matter.  (False means
                              that you have consulted, etc.)

_____ _____ 14. I have considered a divorce or separation a few times other than during or shortly
                               after a fight, although only in vague terms.