Financial Abuse, Economic Abuse and DV

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Please complete and submit this completed Worksheet in order to successfully meet the periodic requirements of this Program.
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.

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: *

YYYY

Time: *

Time

Where do you usually attend Sessions? *

Alamosa

Monte Vista

Trinidad

Walsenburg

Some of the ways that I might have used Economic Abuse or Financial Abuse in my Relationships include: (Please check all that apply). *

I controlled all the money.

I did not let my partner get a job.

I made it difficult for my partner to get or keep a job.

I made my partner give me all of their money.

I spent money using Drugs, Alcohol or other things excessively.

I refused to get a job.

I put my partner down because they made less money than I did.

I accused my partner of cheating on me with people from work.

I refused to regularly pay my share of the bills.

I encouraged my partner to get public assistance such as Food Stamps, Housing and Medicaid so that I would not have to work.

I did not keep a job or jobs that I had.

I blamed my partner for our financial issues.

I made my partner show me receipts for things that they bought.

I gave my partner an allowance rather than letting them manage their own money.

I refused to buy things or services for my partner's children that were not my biological children.

I lied to people when I told them that I would pay them back.

I made my partner use their signature to borrow money or to obtain services that I used.

I broke things that my partner had purchased

I damaged my partner's home or apartment

I made my partner give me money when ever they got money

Required

I hereby commit to finding a way to cease any sort of Financial or Economic Abuse of my partner, other family members, my associates, and those who provide services for me, my partner, and my children. Do you agree with this Statement of Commitment? *

Yes, I Agree with this Statement of Commitment to finding a way to cease any sort of Financial or Economic Abuse as described above and below.

No, I do not Agree with this Statement of Commitment finding a way to cease any sort of Financial or Economic Abuse as described above and below.

Please explain why you answered the question above the way that you did? *

The way I am going to prevent Financial or Economic Abuse of any kind is by doing the following (List below at least 5 ways that you plan to prevent abusive behavior of any kind): *

The way I am going to change my thinking so my thoughts and behaviors will be healthier in relation to Financial or Economic Abuse is by: (List below at least 5 ways that you plan to change your thinking): *

If I realize I am in danger of becoming Financially or Economically abusive I will do the following: (List below at least 5 things that you plan to do if you realized that you are in danger of becoming abusive): *

List some Strengths about you that will make it likely that you will be able to maintain your commitment to eliminating Financial and Economic Abuse in your life. *

How Ready are you to try and keep your live up to your Statement of Commitment to eliminating Financial and Economic Abuse in your life as described above? *

Not at All Ready.

Very Ready.

Please describe how helpful this exercise was for you? In what ways might this show up in your life and relationships in the future? *

I hereby affirm that I it is up to me to try and compute the Balance that I owe to my Provider for my Treatment. I understand that given that the weekly session fee is $35, that I do not have to wait for a Balance in order to start making payments for the Services I am receiving. I am also aware of how I can make payments; either through using a Card or Online Payment App using the links on the Blog; or through mailing payments to my Provider. I also understand that it is my responsibility to start the process of paying for my DV Treatment immediately. And I agree that if do not start making regular payments, I can be Discharged Unsuccessfully from this Treatment without further notice. *

Yes, I am aware of this and I agree to start making regular weekly payments as soon as possible.

Required

I hereby affirm that I am aware that paying for my DV Treatment is a significant part of demonstrating that I am making progress in my Treatment. I am also aware that if I am not making payments at least every two weeks, and if I have a balance due of more than $70 at any time, I can be suspended from DV Treatment and/or Discharged as Unsuccessful without further notice. *

Yes, I am aware of this and I agree to settle my balance within the next two weeks.

Required

Be sure to Click on the "SUBMIT" Button so your work will go to Dr. B.Thank you for completing this form. Be sure to click on the "SUBMIT" Button so that your work will be sent to Dr. Beverly. After submitting this form, click on the X at the top right corner of your screen. Have a nice day? (c. 2020, Dr. Beverly)

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