Intimacy and Prevention of Domestic Violence Worksheet

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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.
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Please respond to the following items Truthfully and Thoughtfully.

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): *

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? *

A Group Tele-therapy Session.

An Individual Teletherapy Session.

A Group Session In-Person.

An Individual Session In-Person.

There was no particular Session (i.e., this is a make-up Assignment).

Where do you usually attend Sessions? *

Alamosa

Monte Vista

Trinidad

Walsenburg

How much Intimacy did you share with your Partner with whom you got your DV Charge? *

None at All

All that is Possible

When thinking about your Relationship in times leading up to your DV Offense; How much Verbal Abuse or Emotional Abuse would you say was happening as done by you? *

None at All

Way too Much!

How abusive were you with the Partner with whom you got this DV offense? *

Not at All

Very

How abusive was the Partner with whom you got this DV offense with you? *

Not at All

Very

When thinking about your Relationship with the person with whom you got your DV Offense; how much did you share the following? *

Not at all

Somewhat

Very much

Honesty

Trust

Respect

Equality

Humility

Forgiveness

Liking

Attraction to

Spontaneity

Compromise

Faith

Self Awareness

Vulnerability

Accountability

Patience

Hope

Unconditional Acceptance

Confidence

Interest

Affection

Affinity

Empathy

Altruism

Sincerity

Collaboration

Acknowledgement

Resolution

Argument

Curiosity

Assertiveness

Appropriateness

Genuinness

Honor

Sympathy

Giving

How frequently did you and this partner express yourselves sexually with this person? *

Never

All the Time

How would you rate your Sex Life with this person? *

Terrible

Incredible

How Helpful is Learning about Intimacy 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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