Partners Zones of Impact Survey

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	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
The ability to think clearly and stay focused.
The capacity to recall and remember important events and details.
The ability to communicate effectively with co-workers, children, family and partner.
The ability to effectively manage hyper-vigilance and preoccupation with signs of betrayal.

	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
The capacity to trust and see the goodness in others.
The ability to feel secure and have stability in moods.
The capacity to be positive and loving.
The ability to be hopeful about the future.

	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
The capacity to feel sexual and desire sexual contact.
The ability to have a positive body image and see self as attractive.
The capacity to experience signs of affection from those other than partner as positive and welcoming.
The ability to maintain a positive view of one’s traits as a woman or man.

	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
The ability to maintain self-care and daily living schedules.
The capacity to have adequate sleep, not too little or not too much.
The ability to maintain good eating habits and appropriate weight.
The ability to refrain from compulsive or addictive behaviors.

	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
	No Impact	Little Imp	Moderate Imp	Significant Imp	High Imp	Extreme Imp
The capacity to see goodness in the world.
The capacity to see one’s self as having importance in the unfolding of life events.
The belief in one’s capacity to positively influence the future.
The ability to believe in the benevolence of God.

Partners Zones of Impact Survey

Developed by Kenneth Adams, Ph.D. (adapted from Zones of Impact by Hope Ray)

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