Attitudes And Types Of Thinking That Might Support and/or Promote DV
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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? *
Have you ever had beliefs, attitudes or thoughts related to the following? *
Yes
No
Row 1-- Thinking that I OWN her or him.
-- Thinking that Relationships are Pemanent and Never Change.
-- Thinking that I Have a Right to Control Who She or he Talks To or Spends Her or his Time With.
-- Thinking that I have Privileges that she or his does not have.
-- Thinking that it is My Right to Control All of The Money.
-- Thinking that I am in a Position to Judge Her About Almost Anything that She or he Does or Believes.
-- Thinking that Because She's Female or He's a Male, She or He is Somehow Less That I am.
-- Thinking that Because She or He has Committed to a Relationship with me That I Don't Have to be Respectful to Her 100% of the Time.
-- Thinking that I can Use The Kids To Get Her To Do What I want Her or Him to do.
-- Thinking that Because She's A Woman or He's a Man thus She or He Is Automatically Responsible for Certain Things such as Cleaning the House, Cooking and Watching the Kids.
-- Thinking that I have a Right to take Sex from Her or Him any time I want because she is my wife or He is my Husband.
-- Thinking that if I suspect (or even think I know) that she or he is Cheating on me, that I have a RIGHT to know the details.
-- Thinking that I get to determine what is and is not FAIR for us regardless of how she or he feels about it.
-- Thinking that it is My job to Teach Her or Him, Molded Her or Him, or to Make her do things the way I Want her or him to.
-- Thinking that whenever we disagree, that it must be settled asap, and that one of us has to be right and the other has to be wrong.
-- Thinking that Because we are together or even married; I have a Right to tell her Family and others to but out of our business.
-- Thinking that Because She or He has me, she or he does not need to have anyone else in her life.
-- If she or he already has kids from before; thinking that her or his other kids are somehow NOT my responsibility and that they should not be tested as well as we treat the children that we share.
-- Thinking that Because She or He chose to leave me; I have a Right to Alienate her / him from our children.
-- Thinking that my behavior when I am stoned or drunk or even blacked out does not count.
-- Thinking that Because I make the money, she or he has no need for Education, Training or even a Job.
-- Thinking that I have the Right to Control where she or he Works and With Whom she or he Works.
-- Thinking that I have a Right to look at her or his Phone -- such as to see his she or he is "cheating".
-- Thinking that When I am Angry, I gave a Right to break anything around the House as long as it is something that I Paid For.
-- Thinking that Because She is a Female or He is a Male, She or He is not as Smart or as Honorable as I am.
-- Thinking that doing this the way my own Family did them is THE WAY it ought to be.
-- Thinking that I have a Right to do things that I Like, even if they hurt her or his feelings.
-- Thinking that it is okay to verbally Disrespect or Threaten Her or Him as long as I do not Hit her.
-- Thinking that it is acceptable for me to intentionally make her or him Jealous and make her or him believe that I am seeing someone else just to manipulate her or him.
-- Thinking that I have the Right to Manipulate Her or Him by Threatening to Kill Myself if She or He doesn't do what I want Her to do
-- Thinking that I have a Right to Call Her or Him Names.
-- Thinking that If I Accuse Her or Him of Cheating that it will Solve anything.
-- Thinking that Because I am Bigger or Meaner or Stronger or Smarter than Her or Him, that I get to make significant decisions (I.e., Choosing a place to live, buying a vehicle, or even naming a child) without seeking her Approval.
-- Thinking that I have a Right to Humiliate her or him in front of others (or even privately), in order to get her to do what I want.
-- Thinking that it is Okay for me to hurt or Threaten to hurt the Kids or Pets when she and I are not getting along.
-- Thinking that I am in a Position to determine what may partner is really thinking it feeling.
-- Thinking that it is okay for me to Stand in a doorway to keep her or him from leaving when I feel that the discussion is not yet over.
-- Thinking that it is understandable and acceptable for me to say and/or do hurtful and/or destructive and/or embarrassing things when I am Angry.
-- Thinking that it is Wrong to get help from a Family Member, Counselor, Therapist, Doctor or Minister when we -- as a couple -- or even either one of us -- as individuals -- are experiencing serious problems.
-- Thinking that it is okay for me to use our funds to purchase Alcohol or Drugs -- even if I have an Addiction.
-- Thinking it is normal for me to NOT Trust her or him -- especially around people of the opposite sex.
-- Thinking that it is Acceptable for me to live off of her Public Assistance Entitlements such avoid Stamps, Housing, Tanif or Disability.
-- Thinking that as a Man, I have "needs", Hence I have a Right to take a Mistress or a Sancha if she or he does not please me the way I want her or him too.
-- Thinking that it is Okay for me to keep, play, watch or listen to offensive and/or demeaning Music or Videos in the Home of, or in the presence of Her or Him and/or the Kids.
-- Thinking that as the Man, it is My Role to intentionally use Power Over, or to Subjugate My Woman or My Man or even the Kids in order to Teach them to Respect Me.
-- Thinking that while in this Relationship, it is Acceptable for me to keep company with people or even family or friends who are disrespectful toward Women / Men or Children in general and/or specifically toward Our Children.
-- Thinking that Because I am the Man or a Woman, I can single-handedly make important decisions regarding our Children.
-- Thinking that it is Okay for me to Tell and Scream in MY House because I feel Angry.
-- Thinking it is Acceptable for me to Drive in a Scary Way when I am Angry.
-- Thinking that during times she we are Troubled, Arguing or Fighting, that I have a Right to mess around with, Clean, Display, Brandish, Train, or even Practice with a Weapon of any kind -- particularly in the presence or, or even on the same property as My Partner and/or the Children.
-- Thinking that He or She does not have a RIGHT to Love or even to Like any other person of the opposite Sex.
Objectively speaking, how well would your Partner say that you do each of the following: *
Doesn't even Try
Okay
Excellent
Always know that you and your Partner are Equals. Treat your Partner like an EQUAL Partner.
Always show RESPECT for your Partner and the Children in every way.
Obtain and Maintain a firm grasp on the Separation of things that you CAN Control from the things that you CANNOT Control.
Work hard to develop a Strong Sense of Empathy for your Partner and your Children.
Learn how to Communicate -- and that Listening is the MOST IMPORTANT Part of Communication.
Commit to always being HONEST with your Partner.
Do the Best you can for your Partner -- every time.
Remember that Fairness is not Fair, unless you both agree that it is Fair.
Never Use the Children in any way to Hurt, Insult, or Relay negative messages to your partner.
Always be Accountable to Your Self and to your Partner.
Please list some changes that you could make that might help you Prevent Domestic Violence in the Future. *
How Helpful is Learning about Attitudes & Thinking that promote DV in Relationships 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? *
RULE 1: Every Week of Participation in this DV Program must be accounted for. RULE 2: No DV Client should miss more than one DV Session for any given 10 weeks in DV Treatment.  Once a DV Client misses 3 DV Treatment Sessions (including Intake, Evaluation, Groups, Individual, Treatment Planning, Denial, or Reinstatement Sessions).  If a DV Client fails to honor either Rule 1 or Rule 2 (above), the Multidisciplinary Treatment Team (MTT) must meet to discuss this matter; then the Client can be discharged from Treatment as "Unsuccessful", required to do additional Treatment(s), and/or Temporarily Suspended from DV Treatment until the issues causing absences are resolved.  This means that every time you miss attending your DV Session (Group or Individual) for one week, you must complete one of these Absence Attestation forms and submit it to Dr. Beverly.  All absences from any type of DV Appointment require that you complete an Absence Attestation form.  Please see the Link to the Absence Attestation Form, below.  Naturally, a Communicated Absence -- where Dr. Beverly is notified at least 24 hours in advance, is looked upon much more favorably than a No Call / No Show or an AWOL Absence.    In order to be considered for a Communicated Absence, you must do this within 48 hours of your absence. Technically, almost all absences should be communicated to Dr. Beverly at least 24 hours prior to your scheduled Session.  If you do not Communicate about your Absence with Dr. B within 48 hours of your Absence, it will be considered a Non-Communicated Absence.   If you have documentation of any kind to send to Dr. B., please do so by photographing or scanning the documentation and emailing it to him.  If you are sending in Documentation, you must still complete this Form and Submit it in order for this to be a Communicated Absence.  Also, please be sure to check out the "Absence Make-Up Assignments" on this Blog, so that when you complete this Form and are asked to state which Make-Up Assignment you plan to complete, you will know what you are committing to.  It is important to note that Make-Up Assignments do not Make-Up for your missing any DV Sessions.  However, if you complete Make-Up Assignments when ever you miss a session, the MTT is more likely to be more lenient on you for missing the sessions that you had to miss.  Although there are no "Excused Absences", Communicated Absences and Absences for which one completes a Make-Up Assignment, are looked upon much more favorably by the MTT than Non-Communicated Absences.  Furthermore, if Absences are Communicated in advance, this is even better.   It is important to note that once a person reaches three (3) Absences of any kind, he or she may be dropped from the Program. *
Required
I understand that if I owe $70 or more for my DV Treatment; I can be subject to not being able to attend DV Sessions until I make a payment plan and begin paying,   *
Required
I understand that it is up to me to keep track of my Balance due for my DV Treatment. *
Required
I understand that if I need to speak with Dr. B about my Balance for my DV Treatment, I will do so by texting him.  I will not try and discuss my private Billing issues in Group. *
Required
I understand that from this point forward in my DV Treatment, I must make a payment every time I attend -- Or at least every 2 weeks at a minimum or else I risk being Discharged without further warning. *
Required
I understand that if I need to speak with Dr. B about my Balance for my DV Treatment, I will do so by texting him.  I will not try and discuss my private Billing issues in Group. *
Required
I understand that whenever I make a payment, I should send Dr. B. a TEXT informing him of the payment so that he can confirm that the payment wen through. *
Required
I understand that I cannot be successfully discharged from DV Treatment if I have a Balance of any kind. *
Required
I understand that if I miss 3 or more DV Sessions for any reason I can be discharged as Unsuccessful with no further notice. *
Required
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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?
  Be sure to click on the "SUBMIT" Button so that your work will be sent to Dr. Beverly.  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?    (c. 2020, Dr. Beverly)(Gracias por completar este formulario.  Asegúrese de hacer clic en el botón "ENVIAR" para que su trabajo sea enviado al Dr. Beverly.  Después de enviar este formulario, haga clic en la X en la esquina superior derecha de su pantalla.  ¿Que tengas un buen día? (c. 2020, Dr. Beverly))  (c. 2021, Dr. Beverly)
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