Treatment Planning for Success in Domestic Violence Treatment (Planificación del tratamiento para el éxito en el tratamiento de la violencia doméstica)
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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?) *
What is your current Risk Level (¿Cuál es su nivel de riesgo actual?) *
List Your Most Powerful Risk Factor / Criminogenic Need (Name the one that has the most to do with your DV offense):   (Enumere su factor de riesgo más poderoso / necesidad criminogénica (nombre el que tiene más que ver con su delito de DV):) *
List Your Second Most Powerful Risk Factor / Criminogenic Need (Name the one that has the most to do with your DV offense):   (Escriba su segundo factor de riesgo más poderoso / necesidad criminogénica (nombre el que tiene más que ver con su delito de DV):) *
List Your Third Most Powerful Risk Factor / Criminogenic Need (Name the one that has the most to do with your DV offense):   (Enumere su tercer factor de riesgo más poderoso / necesidad criminogénica (nombre el que tiene más que ver con su delito de DV):)
List some Strengths that you could use to help you solve these Risk Factors or problems that you listed above:   (Enumere algunas fortalezas que podría utilizar para ayudarlo a resolver estos factores de riesgo o problemas que enumeró anteriormente:) *
Risk Factor #1 / Criminogenic Need / Problem / Area for Improvement 1: (Problema #1): *
Measurable Goal #1 (What will it look like when fixed?  & How long will it take to fix it?): (Objetivo medible #1): *
Plan #1 (In addition to attending all DV Treatment Sessions and Second Clinical Contact Sessions and Completing All Related Assignments, How will you fix this Problem?): (Plan #1): *
Result: Goal #1 Met? or Not Completed? Date / Review Comments: (Fecha / Comentarios Comentarios):
Risk Factor #2 / Criminogenic Need / Problem / Area for Improvement 2: (Problema #2): *
Measurable Goal #2 (What will it look like when fixed?  & How long will it take to fix it?): (Objetivo medible #2): *
Plan #2 (In addition to attending all DV Treatment Sessions and Second Clinical Contact Sessions and Completing All Related Assignments, How will you fix this Problem?): (Plan #2): *
Result: Goal #2 Met? or Not Completed? Date / Review Comments: (Fecha / Comentarios Comentarios):
Risk Factor #3 / Criminogenic Need / Problem / Area for Improvement 3: (Problema #3):
Measurable Goal #3 (What will it look like when fixed?  & How long will it take to fix it?): (Objetivo medible #3):
Plan #3 (In addition to attending all DV Treatment Sessions and Second Clinical Contact Sessions and Completing All Related Assignments, How will you fix this Problem?): (Plan #3):
Result: Goal #3 Met? or Not Completed? Date / Review Comments: (Fecha / Comentarios Comentarios):
How Ready are you to try and  eliminate these Risk Factors from your life? ()¿Qué tan listo está para tratar de eliminar estos factores de riesgo de su vida? *
Not at All Ready. (Nada Lista.)
Very Ready. (Muy Lista.)
Please describe how helpful this exercise was for you?  In what ways might this show up in your life and relationships in the future? (Describa qué tan útil fue este ejercicio para usted. ¿De qué maneras podría aparecer esto en su vida y relaciones en el futuro?)

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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