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Couples Weight Loss Support Survey






Couples Weight Loss Support Program – Clark Coaching and Counseling


Couples Weight Loss Support Program

Welcome to the Couples Weight Loss Support Program by Roy and Dr. Amy Clark of Clark Coaching and Counseling. This interactive tool allows you (the person pursuing weight loss) to complete the Transformation Partner Assessment (TPA). Based on your responses, we’ll generate your Partner Support Profile and provide a customized action plan for your supporting partner. This is designed to help couples support each other through health transformations, focusing on psychological and relational dynamics.

After completing the survey, you’ll see your profile, key needs, and coaching recommendations. For personalized sessions, visit royandamy.com to book a consultation.

Section A: Motivation Type

Rate each statement (1 = Strongly Disagree, 5 = Strongly Agree)

A1. I want to lose weight because my doctor or healthcare provider told me I should.
A2. I want to lose weight because others (family, friends, partner) want me to.
A3. I want to lose weight to receive a specific reward or meet a deadline (event, vacation, etc.).
A4. I would feel ashamed or guilty if I didn’t lose weight.
A5. I feel like I ‘should’ lose weight or I’m a failure.
A6. I want to prove something to myself or others.
A7. I believe losing weight is important for my long-term health.
A8. Losing weight aligns with who I want to be as a person.
A9. I value taking care of my body.
A10. I genuinely enjoy learning about nutrition and healthy eating.
A11. I find satisfaction in physical activity itself, not just the results.
A12. Making healthy choices feels natural and authentic to me.

Section B: Support Preferences

Rate how helpful each type of partner behavior would be for your weight loss journey (1 = Very unhelpful/would feel controlling, 5 = Very helpful/would feel supportive)

B1. My partner reminding me of my health goals when I’m about to make an unhealthy choice.
B2. My partner joining me in healthy eating even if they don’t need to lose weight.
B3. My partner tracking my progress or asking about my weigh-ins.
B4. My partner giving me complete space to manage this on my own.
B5. My partner exercising with me or participating in physical activities together.
B6. My partner praising my healthy choices and celebrating my successes.
B7. My partner adjusting our social activities to support my goals (e.g., different restaurants).
B8. My partner keeping tempting foods out of the house.
B9. My partner asking how they can help without assuming what I need.
B10. My partner listening when I’m struggling without trying to fix it.
B11. My partner expressing confidence in my ability to succeed.
B12. My partner holding me accountable to commitments I’ve made.

Section C: Attachment & Relationship Security

Rate how much each statement describes you in close relationships (1 = Not at all like me, 5 = Very much like me)

C1. I worry that my partner doesn’t really love me or will leave me.
C2. I need a lot of reassurance that I am loved.
C3. I often worry about being abandoned.
C4. When I’m stressed, I want my partner close to me.
C5. I find it difficult to depend on romantic partners.
C6. I prefer not to show a partner how I feel deep down.
C7. I am very comfortable being close to romantic partners.
C8. I find it easy to depend on others.
C9. I don’t worry about being alone or about others not accepting me.

Section D: Trigger & Vulnerability Assessment

Rate how much each situation triggers unhealthy eating for you (1 = Not at all, 5 = Very strongly)

D1. When I feel stressed or overwhelmed
D2. When I feel sad, lonely, or depressed
D3. When I feel angry or frustrated
D4. When I feel bored
D5. When I feel happy and want to celebrate
D6. When certain foods are visible or available in my environment
D7. When others around me are eating unhealthy foods
D8. During social gatherings or events
D9. When my partner and I have conflict or tension
D10. When I feel criticized or judged about my weight or eating
D11. Late at night or when I’m tired
D12. When I’ve already ‘slipped up’ and feel like the day is ruined
D13. List specific foods that are hardest for you to resist:
D14. List situations or places that trigger unhealthy eating:
D15. What partner behaviors have previously derailed your efforts? (Check all that apply)








Section E: Stage of Change

E1. Which statement best describes where you are right now? (Select one)




E2. How many previous weight loss attempts have you made?



E3. What has typically caused previous attempts to end? (Check all that apply)







Section F: Relationship Dynamics & Weight

Rate your agreement with each statement (1 = Strongly disagree, 5 = Strongly agree)

F1. My partner is fully supportive of my decision to lose weight.
F2. I worry that losing weight might change our relationship.
F3. My partner has expressed concerns about my weight loss efforts.
F4. Food and eating together is an important part of our relationship.
F5. I feel comfortable talking to my partner about my body and weight.
F6. My partner’s eating habits make it harder for me to eat healthy.
F7. I worry my partner may feel threatened if I lose weight.
F8. My partner and I have different views on what healthy eating looks like.
F9. I would like my partner to make some health changes too.
F10. I feel my partner accepts me regardless of my weight.
F11. How would you describe your partner’s current health/fitness status?





Your Partner Support Profile

Action Plan for Supporting Partner

To get personalized coaching from Dr. Amy and Roy Clark, visit royandamy.com and book a session. Integrate this with your fitness trainer for full support.



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