My Journey from Trauma to Hope 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.
Sign in to Google to save your progress. Learn more
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
/
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? *
Please describe your DV Offense In 1 (One) Sentence. *
Please describe the Trauma that might have been experienced by anyone during (before and after) your DV Offense: *
Please indicate your level of experience of the following feelings, thoughts or sensations in relation to your DV Offense (including feelings, thoughts or sensations experienced Before, During and After your Offense; as well as your assumptions about the experiences of others): *
Zero
Not Enough
Some
A Lot
Too Much
Your Trauma(s)
The Victim(s) Trauma(s)
The Witness(es) Trauma(s)?
The 3rd Party(ies) Trauma(s)?
Denial related to this process?
Your sense of playing or actually being Victim in this Process?
Grieving during this process?
Sorrow during this process?
Anger during this process?
Bargaining (or tried to change the outcome in my mind) during this process?
Depression during this process?
Anxiety, Nervousness or Panic during this process?
Forgiveness for Others during this process?
Forgiveness for Your Self during this process?
Apology during this process?
Opportunity (for good or bad) during this process?
Acceptance of FACTs during this process?
A sense of Helplessness during this process?
Gratitude during this process?
Humility or Humbleness during this process?
Survivorship during this process?
Acceptance of Self during this process?
Accountability during this process
A sense of Re-Birth or Renewal during this process?
Confidence during this process?
Hope and/or Faith during this process?
NOW: Think to yourself......... Breathe deeply for a moment....... How do you feel right now? *
My Journey from Trauma to Hope & Confidence *
Ben Okri said, "The most authentic thing about us is our capacity to create, to overcome, to endure, to transform, to love and to be greater than our suffering."  What does this idea mean to you right now? *
What has learning about your journey from Trauma to Hope and Confidence 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 your journey from Trauma to Hope and Confidence 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? *

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.

 *
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).
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Dr. William T. Beverly, LCSW. Report Abuse
Google Forms