My Helpful Supports Give & Take Worksheet
  Please complete and submit this Worksheet in order to successfully meet the requirements of this Topic.  
  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.  (Escriba las primeras 3 letras de su nombre.) *
Please type in the first 3 letters of your last name.  (Escriba las primeras 3 letras de su apellido.) *
What year were you born?  (¿En qué año naciste?) *
Date (Feche): *
MM
/
DD
/
YYYY
Time (Tiempo): *
Time
:
Where do you usually attend Sessions?  (¿Dónde sueles asistir a las sesiones?) *
Which type of Session did you do that relates directly to this Worksheet? *
How Much Support do you receive  (or have you in the past received) from each of the following resources? *
Zero
Some
A Lot
Social Services
TANF
Food Stamps
The Taxpayers
Church-Based Charities
Family Members
Medicaid / Medicare
Volunteer Organizations
Schools
Services such as Water / Electric
Police
Fire
Health: Free Clinics
Job Corps
Unemployment / Workforce Center
Ambulance / Rescue
Disability
Emotional Supports
Instrumental Supports / Mentoring / Job Coaching
Tangible Supports
Friends
Alcoholics Anonymous / Narcotics Anonymous
Probation Paying for Services that you receive
Food Pantry
Strangers on the Street
Educational Services / Tutoring / Schools / Training Providers
Treatment Providers / Therapists / Counselors
The VA
Boys or Girls Clubs / YMCA/YWCA / Scouts
Bible Study Group / Other Reading Group
Your Parents
Your Brothers and Sisters
Your Children
Distant Family Members
Your In-Laws
What do you think of people who accept and use supports such as those listed above? *
How do you feel when you accept support such as that  listed above? *
How Much Support do you give (or have you given in the past given) to each of the following entities or people? *
Zero
Some
A Lot
Social Services
TANF
Food Stamps
The Taxpayers
Church-Based Charities
Family Members
Medicaid / Medicare
Volunteer Organizations
Schools
Services such as Water / Electric
Police
Fire
Health: Free Clinics
Job Corps
Unemployment / Workforce Center
Ambulance / Rescue
Disability
Emotional Supports
Instrumental Supports / Mentoring / Job Coaching
Tangible Supports
Friends
Alcoholics Anonymous / Narcotics Anonymous
Probation Paying for Services that you receive
Food Pantry
Strangers on the Street
Educational Services / Tutoring / Schools / Training Providers
Treatment Providers / Therapists / Counselors
The VA
Boys or Girls Clubs / YMCA/YWCA / Scouts
Bible Study Group / Other Reading Group
Your Parents
Your Brothers or Sisters
Your Children
Distant Family Members
Your In-Laws
What do you think of people who freely give or contribute to supports such as those listed above? *
How do you feel when you accept support such as that  listed above? *
How might Social Supports (and other Supports) Help Prevent Domestic Violence?
In your lifetime, how HELPFUL have resources -- such as those listed above been for you and your family?
Not Helpful At All
Extremely Helpful
Clear selection
How Helpful is Learning about Helpful Supports, Give and Take 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? *
Very Negatively
Very Positively
Please describe how helpful this exercise was for you? *
  I understand that once I start my DV Treatment, I am supposed to meet with Dr. Beverly -- either in a Group Session or Individually -- every week.  If I do not meet with Dr. Beverly during a given week, I understand that it is my duty to complete an Absence Attestation and a Make-Up Assignment (as listed on the Absence Attestation Posting on the BLOG).  Further, I understand that every week, it is my duty to complete the Worksheet(s) and the Session Feedback From for that week, as listed at the bottom of the Weekly Topic posting.  I understand that if I fail to complete any of these Worksheets or Sessions Feedback Forms, I may not successfully complete my DV Treatment. *
Required
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Dr. Beverly.  After submitting this form, click on the X at the top right corner of your screen.  Have a nice day? (c. 2021, Dr. Beverly)
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