Finding Serenity to Prevent DV 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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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
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DD
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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? *
Think about your Partner -- particularly the Partner that you were with when you had your DV Offense: Name three things about your Partner that you feel contributed to you getting a DV Offense? *
Which ones of those three things about your Partner that you listed above were (or are) you able to control? *
Think about Your Self -- particularly the Self that you were when you had your DV Offense: Name three things about Your Self that you feel contributed to you getting your DV Offense? *
Which ones of those three things about Your Self that you listed above were (or are) you able to control? *
To what Degree were you ABLE to Control the things that your Partner did that Contributed to your DV Offense? *
Not at all Able
Totally Able
To what Degree were you ABLE to Control the things that You did that Contributed to your DV Offense? *
Not at all Able
Total Able
Name some things you feel that you can be Grateful for? *
Name some things that might have been difficult for your to Accept in Life: *
What are some things that make you feel unsettled? *
What are some things that you love? *
To what Degree are you ABLE to Control the things that your Partner Thinks About? *
Not at all Able
Totally Able
To what Degree are you ABLE to Control the things that your Partner or does? *
Not at all Able
Totally Able
To what Degree were you ABLE to Control the things that you Think about? *
Not at all Able
Totally Able
To what Degree were you ABLE to Control the things that You do? *
Not at all Able
Totally Able
How Helpful is Learning about Finding Serenity 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? *
Per the Release of Information that I signed upon entry into DV Treatment; I acknowledge that I understand and I agree that throughout the duration of my DV Treatment with Dr. Beverly, Dr. Beverly and/or his Associates will be discussing my DV Treatment Progress with my Probation Officer, the Court, my Mental Health Therapist (if I have one), My Substance Abuse Treatment Therapist (if I have one), and The DV Victim Advocate.  And they too will be disclosing to Dr. Beverly and/or his Associates information about my Treatment Progress and other information as it pertains to their interaction(s) with me while I am in DV Treatment.   These disclosures may include information related to my Mental Health Treatment Progress, any Substance Abuse Treatment Progress, any Testing Results, and the Progress of my Legal Case(s). *
Required
  Please read this important notice: Important Notice Re: Paying for DV Treatment & To Avoid a Possible Negative Discharge  Per the Treatment Contract, the Rules the DVOMB and Probation, paying for your DV Treatment and Staying Current on Your Account Balance is Mandatory.  Per the notice given at the end of Jan. 2022, anyone who is more than $70 behind on payments for DV Treatment AND anyone who has not made a payment in the last 2 weeks will have to be Temporarily Suspended and/or Negatively Discharged from DV Treatment.    If you have NOT had confirmed Vouchers and if you have NOT made such payments, you are likely to be discharged or suspended from DV treatment as of Monday Morning 3/7/22 or soon thereafter.    Even If you have had a Voucher to cover the last two weeks; If you had a previous IOU Balance and you did not make a payment in the last 2 weeks you are likely to be Negatively Discharged or Suspended from DV treatment on Monday 3/7/2022 or soon thereafter.    If Discharged, you will have to Re-Start DV treatment, which also can have associated financial costs and other problems such as a possible extension of Probation.  Make A Payment Now!  You do not need to get a balance from Dr. B in order to add up what you owe.    It is simple: If you have Attended a DV Session, it must be paid for.  And if you P.O. did not give you a Voucher, then it is up to you to pay for it.  Additionally, If your total missed weekly classes reaches 3 -- for any reason (suspended or not) -- you are likely to be Negatively Discharged from Treatment Next Week.    If you have questions on how to make a payment please Go to the blog; Scroll to the bottom of your screen; Press the view as web version Link; Enlarge the PayPal / Debit / Credit Card Buttons and make your payment.  Be sure to put your name in the space above the dollar amount.  When you do make a payment, please text me at 719-671-7793 and inform me that you made that payment, so that I can confirm it for you.  If you do not know your current Balance, then add up $100 for your Intake/Evaluation and then add $35 for each Session you have attended.  Then Subtract your number of Vouchers that were used on time.  You can do this.  If you do not know about the status of your possible treatment vouchers, please text me and I can try and Enlighten you on that.  Do not get Negatively Discharged! *
Required
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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