Dr. B's DV Prevention Session Feedback
This is a form that People complete following Sessions with Dr. B.  Please be advised that your responses here will be confidential.  However, in order to assist in that effort, please follow the instructions below closely.  
PLEASE Be Sure to hit SUBMIT before you exit this page so that your Response will be counted.
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Email *
Please type in the first 3 letters of your first name. *
Please type in the first 3 letters of your last name. *
What year were you born? *
What was the date of this Session? *
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What was the time of this Session? *
Time
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In which format was this Session? *
Where do you usually attend Sessions? *
What was the topic of this Session? *
What is the single most important thing you learned today in Session? *
How does this lesson you learned today apply directly to you and your goals for treatment? *
Please rate how helpful this treatment is to you in your life? *
Not Helpful
Very Helpful
What could be done differently to make this treatment more helpful to you? *
Please rate your level of depression this past week? *
Not at all Depressed
Very Depressed
Please rate your level of anxiety/stress/tension this past week? *
Not at all Anxious
Very Anxious
Please rate your level of anger this past week? *
Not at all Angry.
Very Angry.
Please rate your level at which you and your current partner have been getting along this past week: *
Not at All.
Very Well.
How much have you been using the skills that you are learning in this class with your current relationship?  ***NOTE:  If you don’t currently have a partner.  Please describe three nice things about your future partner? *
Not at All.
Very Much.
List three nice things about your current partner.  ***NOTE:  If you don’t currently have a partner.  Please describe three nice things about your future partner?                       *
Assistance for Emergencies and Crises and Disclaimer: 
  Please acknowledge below that you understand that your responses to Dr. B's Online Surveys, Questionnaires, and/or Worksheets are NOT Monitored on a daily or a consistent basis and that if you have a Mental Health-Related or DV-Related Emergency or Crisis; or if you need to communicate with Dr. B. in a timely fashion, that this Online form is NOT the way to do it and Dr. B. cannot be responsible for receiving any timely communications via this platform.   
  If you are having a Medical Emergency, please dial 911, and/or go to the nearest Emergency Room.  
  If you are having a Mental Health Emergency or Crisis, please dial the Suicide Crisis Lifeline at 988.  
  Or, you can contact their CHAT Service at Lifeline Chat. 
  Or, you may Text HOME to 741741 free 24/7, to contact the Crisis Text Line for any Crisis so that you can Text with a Trained Crisis Counselor.
  If you are a client of Dr. B's and you are in Crisis, please call him at 719-671-7793 (24/7).
  Otherwise, If you feel a need to communicate something to Dr. B. that is not a Crisis or an Emergency, please feel free to email him at nepeht@gmail.com.  Or you may Text Dr. B. at 719-671-7793.  
  Please acknowledge below that you have received this information and that you understand its contents.
 *
Thank you for completing this form.  Be sure to click the "SUBMIT" Button so that your responses will go to Dr. Beverly.  Also, after you are done with that,  click on the X at the top right corner of your screen.  Have a nice day?
A copy of your responses will be emailed to the address you provided.
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