My Anger Management Thermometer & DV Prevention Worksheet
  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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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? *
Rank each of the following topics that you might discuss with your partner, as to how angry it can make you feel if during a discussion, things start to go off the deep end.   Indicate below (as if on a  thermometer) how angry each topic makes you feel at times.  (If you don't have a partner right now, you may use either your Ex- or in relation a possible future partner).   *
Calm
Frustrated
Angry
Furious
Sex
Money
Kids
Timing
Quality Time
Romance
Chores
Pet Peeves
In-Laws
Jealousy
Being Interrupted
Being Ignored
Being talked about on FB
Being Rejected
Being Followed
Being Talked About in a Negative Way
How Likely are you to use each of the following Strategies to Help Control Your Anger or to prevent Angry Behavior? *
Not Very Likely
Somewhat Likely
Very Likely
Acknowledge that you have a problem.
Keep a Hostility Log.
Use Your Support Network.
Interrupt the Anger Cycle.
Use Empathy.
See the Humor in your Anger.
Relax.
Build Trust.
Listen Effectively.
Be Assertive.
Live Each Day as if it's Your Last.
Forgive and Forget.
Anger Cues are sensations that we get in our mind or our body that tell us that we are getting really angry.  What Anger Cues have you experienced? *
Never
Sometimes
Frequently
Sweaty Palms
Headache
Tummy Problems
Shakey
Hold your hands behind your back
Start yelling
Run away real fast
Feel like the World is ending
Have a Panic Attack
Crave Alcohol or Marijuana
Want to eat
Want to settle things right away
Want to ignore what just happened
Want your partner to tell you that everything is going to be alright
Can't stop talking
Forget to listen to the other person
Bite your fingernails
Need a Hug
Want to be Alone
Get Angry at Yourself for Feeling Angry
Anger Cues are sensations that we get in our mind or our body that tell us that we are getting really angry.  Can you think of any Anger Cues that have you experienced that are NOT listed above? *
How often do you feel that you have had a problem with your Anger? *
Never
Frequently
Please Describe what you feel like when you are at your angriest: *
Please Describe what you think like when you are at your angriest: *
Please Describe what you look like when you are at your angriest: *
Please Describe what you talk like when you are at your angriest: *
Please Describe act like when you are at your angriest: *
How helpful is Out-of-Control Anger when you express it with your Partner? *
Not Helpful at All
Very Helpful
What has learning about your Anger and Anger Management taught you about prevention of DV? *
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
How helpful is learning about learning about Anger, Anger Management and DV going to be toward helping you prevent all types of DV in your life in the future? *
Not very helpful at all.
Very helpful.
Please describe how helpful this exercise was for you? *
  Please NOTE: Fees for Treatment are always expected before services are rendered.  There are no IOU’s for Treatment Services.  All payments are due at the time of service.  If there is an extraordinary circumstance and you cannot pay for treatment on the date of service, please contact Dr. Beverly privately (via text) to see if you can make arrangements to pay in advance or otherwise.  If a Consumer is hoping to be awarded a Voucher to pay for services, such arrangements are 100% between the Consumer and her or his Probation Officer.  Please make such arrangements directly with your Probation Officer.  It is also recommended if in need of a Voucher, Consumer’s should contact their Probation Officer as far in advance as possible.  (*** Please NOTE: Dr. Beverly accepts Cash, Debit/Credit Cards, Money Orders, Various Insurances and approved Vouchers for Treatment.  He will accept personal checks at his discretion.  If a Personal Check Bounces the person issuing the check will have to pay a $30 fee in addition to the original amount of the check.)  That being said (above), please note that Dr. Beverly is not really set up to easily send out Detailed Invoices.  Therefore, the best option for everyone is to pay as you go.  This can be done by going to the "View as Web Version" view of the Blog and select the appropriate PayPal Button and pay for the services you just received.  Thank 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. 2020, Dr. W. T. Beverly).
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