Purpose Statement and Understanding of
The Gottman Relationship Checkup Assessment

I understand that The Gottman Relationship Checkup Assessment (“Gottman Relationship Checkup” or “Checkup” or “Assessment”) consists of a group of questionnaires that have been designed to provide insight into a couple’s relationship. I understand that the Assessment is designed to obtain a general assessment and profile of a couple’s relationship. I understand that it is not designed to provide a global satisfaction or happiness score, nor is it designed to formulate a diagnosis. I recognize that this Assessment will not predict whether a couple will stay together or divorce. It does not serve to predict who is a good, bad, or better parent in a custody decision. Instead, I understand that the purpose of The Relationship Checkup Assessment is that it may be used to determine areas that may represent strengths or challenges for a couple and may provide useful suggestions for treatment. I understand that all people and couples are different, and that no guarantees can be made as to usefulness or accuracy of results related to the Checkup.

HIPAA Statement: I understand that at the beginning of therapy, U.S. Federal Health Insurance Portability and Accountability Act (HIPAA) law requires that an independently practicing clinician who is considered a Covered Entity by HIPAA must present each client with a Notice of Privacy Practices (NPP). I have been informed that it is the responsibility of each clinician using this site for assessment purposes who is a Covered Entity to provide such a document to their clients as well as to obtain consent for use of unencrypted email as a source of communication. Because the link to this assessment tool is sent to the client using an email address, this consent should be obtained prior to the link to the checkup assessment being provided. The Gottman Relationship Checkup Assessment Site has been developed to be compliant with HIPAA regulations. The site uses 256-bit SSL encryption to secure the connection. The software that the site runs on is actively monitored and kept up-to-date with prompt application of the latest security patches stored in a secured cloud. Clinicians are responsible for obtaining informed client consent from individuals authorizing the use of the client’s personal email as a means of communication.

Training and Licensure: Prior to using this assessment tool, I confirm that I have completed the clinical training necessary to provide accurate, informed, ethical relationship counseling to couples. I confirm that I have obtained the licensure for practice appropriate to my training if licensure is required in the state (or country or jurisdiction) in which I provide counseling services. The Gottman Institute provides comprehensive trainings to professionals from a variety of backgrounds and disciplines. Information about training resources can be found at https://www.gottman.com/professionals/training/.

Feedback: We welcome your feedback and would love to hear from you! If you have additional questions about the Relationship Checkup Assessment Tool or other Gottman Connect services, please contact [email protected].