Risk Factors for Intimate Partner Violence Perpetration (per the CDC)
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  Please respond to the following items Truthfully and Thoughtfully.

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Worksheet Developed by Dr. Beverly (May 2020)
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Email *
Please type in the first 3 letters of your last name followed by the first 3 letters of your first name.  After this, type in the year you were born. *
Please list Today's Date (Feche), the Current Time, and the City where your Probation Office is: *
Please Don't Be Shy!  This exercise can really help you to never again have a DV event or a DV Charge.
According to the CDC: "Risk factors are linked to a greater likelihood of intimate partner violence (IPV) perpetration. They are contributing factors, but might not be direct causes. A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of IPV. Understanding these multilevel factors can help identify various opportunities for prevention."
Which is the listed Risk Factors (below) do you feel could be related to you and/or your Life? *
Closely Related to my Life
Somewhat Related to my Life
Not at all Related to me or my Life.
Low self-esteem
Low education or income
Young age
Aggressive or delinquent behavior as a youth
Heavy alcohol and drug use
Depression and suicide attempts
Anger and hostility
Lack of nonviolent social problem-solving skills
Antisocial personality traits and conduct problems
Poor behavioral control and impulsiveness
Traits associated with borderline personality disorder
History of being physically abusive
Having few friends and being isolated from other people
Economic stress (e.g., unemployment)
Emotional dependence and insecurity
Belief in strict gender roles (e.g., male dominance and aggression in relationships)
Desire for power and control in relationships
Hostility towards women
Attitudes accepting or justifying violence and aggression
History of physical or emotional abuse in childhood
Which is the listed Risk Factors (below) do you feel could be related to you and/or your Relationship? *
Closely Related to my Life or Relation- ship
Some- what Related to my Life or Relationship
Not at all Related to me or my Life or Relationship
Relationship conflicts including jealousy, possessiveness, tension, divorce, or separations
Dominance and control of the relationship by one partner over the other
Families experiencing economic stress
Unhealthy family relationships and interactions
Association with antisocial and aggressive peers
Parents with less than a high-school education
Witnessing violence between parents as a child
History of experiencing poor parenting as a child
History of experiencing physical discipline as a child
Which is the listed Risk Factors (below) do you feel could be related to you and/or your Relationship? *
Closely Related to my Life & Relation- ship
Some- what Related to my Life & Relation- ship
Not at all Related to me or my Life & Relation- ship
Relationship conflicts including jealousy, possessiveness, tension, divorce, or separations
Dominance and control of the relationship by one partner over the other
Families experiencing economic stress
Unhealthy family relationships and interactions
Association with antisocial and aggressive peers
Parents with less than a high-school education
Witnessing violence between parents as a child
History of experiencing poor parenting as a child
History of experiencing physical discipline as a child
Which is the listed Risk Factors (below) do you feel could be related to you and/or where you grew up and/or how you grew up? *
Closely Related to my Life.
Some- what Related to my Life.
Not at all Related to me or my Life.
Communities with high rates of poverty and limited educational and economic opportunities
Communities with high unemployment rates
Communities with high rates of violence and crime
Communities where neighbors don’t know or look out for each other and there is low community involvement among residents
Communities with easy access to drugs and alcohol
Weak community sanctions against IPV (for example, unwillingness of neighbors to intervene in situations where they witness violence)
Traditional gender norms and gender inequality (for example, the idea women should stay at home, not enter the workforce, and be submissive; men should support the family and make the decisions)
Cultural norms that support aggression toward others
Societal income inequality
Weak health, educational, economic, and social policies or laws
Which is the listed Risk Factors (below) do you feel could be related to you and/or your Life? *
Closely Related to my Life
Some- what Related to my Life
Not at all Related to me or my Life.
History of violent victimization
Attention deficits, hyperactivity, or learning disorders
History of early aggressive behavior
Involvement with drugs, alcohol, or tobacco
Low IQ / Learning Challenges
Poor behavioral control
Deficits in social cognitive or information-processing abilities
High emotional distress
History of treatment for emotional problems
Antisocial beliefs and attitudes
Exposure to violence and conflict in the family
SOLUTION #1: Out of the various Lists of Risk Factors ABOVE that you identified above as having to do with your, your life growing up, or your relationship or your community, please list here below the one that impacts your life the most right now.  And then beside this one, describe a way that you could avoid having that Risk Factor effect your Relationships in the future. *
SOLUTION #2: Out of the List of Risk Factors that you identified above as having to do with your, your life growing up, or your relationship or your community, please list here below ANOTHER ONE from above one that also impacts your life a good bit right now.  And then beside this one, describe a way that you could avoid having that Risk Factor effect your Relationships in the future.  (Whatever you do, DO NOT leave this blank.) *
SOLUTION #3: Out of the List of Risk Factors that you identified above as having to do with your, your life growing up, or your relationship or your community, please list here below ANOTHER ONE from above that also impacts your life a good bit right now.  And then beside this one, describe a way that you could avoid having that Risk Factor effect your Relationships in the future.  (Whatever you do, DO NOT leave this blank.) *
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?) *
Untitled Title
Thank you for completing this form.  Be sure to click on the "SUBMIT" Button so that your work will be sent to
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)
  Citing the CDC above: https://www.cdc.gov/violenceprevention/intimatepartnerviolence/riskprotectivefactors.html

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