Moving Forward In A Smarter Way
  Please complete and submit this Worksheet in order to successfully meet the requirements of this Module.
  Please be advised that your responses here will be confidential.  However, in order to assist in that effort, please follow the instructions below closely.  
  Also, be sure to click on the "SUBMIT" Button at the bottom of this Worksheet after you have completed all items, and before you exit this page so that your Response will be counted.
  Once you have completed this worksheet and submitted it, please be sure to clear this from your browser.
  Please respond to the following items Truthfully and Thoughtfully.
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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?   *
Date of this Session related to this Worksheet?  (If there was no Session, please just put in today's date): *
MM
/
DD
/
YYYY
Time of the Session related to this Worksheet?  (If there was no Session, please just put in today's date): *
Time
:
Which type of Session did you do that relates directly to this Worksheet? *
Where do you usually attend Sessions? *
What are some Changes You Would Like to See Made in any one of Your past or present Relationship Situations? *
What do you Want to happen here?  What do you feel SHOULD Happen here?   *
What is your degree of CERTAINTY that the other PERSON involved in this Relationship truly believes that this Relationship Should Happen -- meaning they want this Relationship to Be? *
Not Certain at all
100% Certain
When considering all of the FACTS involved here; What truly SHOULD HAPPEN? *
Is there is a Possibility that you could influence a Change in this Situation.  If you could; what would this change be? *
If you did take Action; who could LOSE WHAT? *
If you did take Action; who WIN or GAIN WHAT? *
What is your degree of CERTAINTY that you SHOULD Act at this point to make this change? *
Not Certain at all
100% Certain
If you made a decision to take action; what would you do in the process of acting to make this change? *
Approximately How Often do you Learn Something NEW? *
Every Day
Rarely
How Helpful is Learning about Smarter Decision Making in Relationships going to be for you in your efforts to prevent DV in your life? *
Not very helpful at all.
Very helpful.
How Negatively or Positively has this DV Treatment impacted your Life? *
A Lot More Negatively than Positively Impacted.
A Lot More Positively than Negatively Impacted
Please describe how helpful this exercise was for you? *
Be sure to Click on the "SUBMIT" Button so your work will go to Dr. B.  Thank you for completing this form.  After submitting this form, click on the X at the top right corner of your screen.  Have a nice day?   This Worksheet (c. 2021, Dr. W. T. Beverly).
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