Risk Factors for Re-Offense
  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: *
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Time: *
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Where do you usually attend Sessions? *
  The primary objective for EVERY DV Offender Graduating from Dr. B’s DV Treatment is that they would never again commit or be accused of Domestic Violence.
  In this Exercise, you will be Identifying 5 of the Potential Risk Factors for Re-Offense that might apply to you, your history, and/or your DV Offense.  Then on the line below each you will explain what you plan to do in order to prevent yourself or anyone else being negatively impacted by this Risk Factor.
How Likely are you to have a DV-Related Re-Offense? *
I am NOT al all Likely to Re-Offend.
I am Very Likely to Re-Offend.
How Likely are you to have DV-Related Thinking and / or Behaviors in your Life in the Future? *
I am NOT at all Likely to Have DV-Related Thinking and/or Behaviors.
I am Very Likely to Have DV-Related Thinking and/or Behaviors.
Select FIVE (5) of the Risk Factors Listed Below to that are mostly likely to be related to your life in some way in the future:
   Dropping out of treatment before treatment is completed; Fewer sessions completed; Younger in age; Unemployed; Less education; History of More psychological Abuse; History of More anger; History of More depression; Unchanged attitudes about women; Higher respect; Using more discussion (Unable or Unwilling to Take Time Outs or to use Stop, Breathe, and Focus when a conversation is becoming Disrespectful); Failure to complete treatment; Lower social support; Lower internal locus of control (Less ability to own my own thoughts and/or actions); Higher perceived stress; Poor problem solving skills; Poor communication skills (Difficulty Communicating Respectfully when Angry, Upset, Insecure or Happy); Lower feminist awareness (Lower Awareness about Sexism or the Impact of Oppression on Victims); Lower awareness of ones psycho-dynamics (Ego, Id, Super-Ego + Social); Poor alliance with therapist (Unable or Unwilling to Trust or Be Genuine with the Therapist); Personality disorders including: Borderline, Avoidant, Antisocial, Self-Defeating, Schizoid, Aggressive/Sadistic, and Passive-Aggressive; Increased psychopathic traits or tendencies; Substance Abuse difficulties; Poor family relations; Child behavior problems (Having a Child with serious problems; and/or having a History of serious behavior problems as a child);  Having a child with the victim; Lower Social Economic Status in Community; Lower Socio-Economic Status; Having been abused as a child; and History of Trauma.
My FIVE (5) Risk Factors that are most like to negatively impact my life or the lives of others in the future include the following.  Please list at least 5 Risk Factors here.  (Remember, you MUST list at least 5 potential Risk Factors here in order to successfully complete this assignment.)   *
My First (1st) Risk Factor ls listed here.  AND NEXT: Listed beside this Risk Factor, are some ways I am going to Prevent this Risk Factor from negatively impacting My Life or the Lives of Others in the Future.   *
My Second (2nd) Risk Factor ls listed here.  AND NEXT: Listed beside this Risk Factor, are some ways I am going to Prevent this Risk Factor from negatively impacting My Life or the Lives of Others in the Future. *
My Third (3rd) Risk Factor ls listed here.  AND NEXT: Listed beside this Risk Factor, are some ways I am going to Prevent this Risk Factor from negatively impacting My Life or the Lives of Others in the Future. *
My Fourth (4th) Risk Factor ls listed here.  AND NEXT: Listed beside this Risk Factor, are some ways I am going to Prevent this Risk Factor from negatively impacting My Life or the Lives of Others in the Future. *
My Fifth (5th) Risk Factor ls listed here.  AND NEXT: Listed beside this Risk Factor, are some ways I am going to Prevent this Risk Factor from negatively impacting My Life or the Lives of Others in the Future. *
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 acknowledge that I understand and that I agree that in order for me to Successfully Complete DV Treatment; all of my DV Sessions, Evaluations and Treatment Plans must be completed and paid for. I understand that if I have questions about any of this, I should TEXT Dr. Beverly at 719-671-7793 as soon as possible and ask him to help me clarify these instructions. *

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, if needed, 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.

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