Accountability for What is Perceived as Domestic Violence Worksheet
  Complete and Submit this Worksheet in order to demonstrate what you have learned about 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.
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? *
What was the date of this Session? *
MM
/
DD
/
YYYY
What was the time of this Session? *
Time
:
Where do you usually attend Sessions? *
What was the topic of this Session? *
What were you accused of doing? *
Who was the Victim in this Offense? *
What did you actually do? *
What consequences did you get as a result of this behavior? *
How do you feel about what you did at this point? *
What  were you  thinking at the time of your offense? *
What could you do differently? *
How Responsible / Accountable do you feel about this at this point? *
What have you learned in your DV Treatment that might help you do better if something like this arises in the future? *
Please rate how Accountable you currently feel for your Offense? *
Not at All Accountable.
Very Accountable.
Please describe how helpful this exercise was for you?  In what ways might this show up in your life and relationships in the future? *
I. This Offender Contract is the treatment agreement between the Approved Provider (Dr. Beverly) and you (the Consumer).  This agreement specifies the responsibilities and expectations of the offender (Consumer), the Approved Provider, and the MTT.    A. Your Responsibilities as the Offender, Client or Consumer in Domestic Violence (DV) Treatment:The Consumer shall agree to and agree to uphold the following as they relate to his/her behaviors and obligations as required by the Colorado Domestic Violence Offender Management Board Standards for Treatment with Court Ordered Domestic Violence Offenders (5 - 11 9/10).  Please NOTE: A copy of the DVOMB’s Standards for DV Offender Treatment may be obtained and/or reviewed 24/7 at no charge by going to the following Web Address: http://cdpsdocs.state.co.us/dvomb/Standards/standards.pdfThe Offender shall:   1. You, as the Consumer agree to be free of all forms of “domestic violence” during the time in treatment.  Domestic Violence includes the term as defined in Section 18-6-800.3(1), C.R.S. Colorado Revised Statutes (C.R.S) and is expanded to include the following definitions for the purpose of the approved provider's use in treatment:  a. Physical violence: aggressive behavior including but not limited to hitting, pushing, choking, scratching, pinching, restraining, slapping, pulling, hitting with weapons or objects, shooting, stabbing, damaging property, or pets, or threatening to do so;  b. Sexual violence: forcing someone to do something that is uncomfortable or demeaning for them, forcing them to perform any sexual act without consent, unwanted, uninvited, or inappropriate sexting;  c. Psychological violence: intense and repetitive degradation, creating isolation, threats of physical harm to victim or other person(s), digital stalking or digital harassment using any digital means, coercing someone to where they hurt themselves or others, and controlling the actions or behaviors of another person through intimidation (such as stalking or harassing) or manipulation to the detriment of the individual;  d. Economic Deprivation/Financial Abuse: use of financial means (or money) to control the actions or behaviors of another person. May include such acts as withholding funds, taking economic resources from intimate partner, threatening someone’s work or job, harassing, or talking someone at or involving their place of employment, and using funds to manipulate or control intimate partner.  2. You, as the Consumer agree to meet financial responsibilities for evaluation and treatment – meaning you must pay for your treatment or make arrangements for someone else to pay for your treatment.  And payment is due at the time of service;  3. You, as the Consumer agree to keep in appropriate and timely contact with your Probation Officer regarding such issues as treatment planning, second clinical contacts, and discussing help with payments for treatment;    4. You, as the Consumer agree to not to use alcohol or drugs (including marijuana); to agree not to use illegal drugs and not to use drugs illegally. This includes misuse or abuse of prescribed medications. If substance abuse treatment is indicated, offender consumer shall complete the substance abuse treatment and abide by any conditions that may be applied as determined by the substance abuse evaluation;  5. You, as the Consumer agree to sign releases of information allowing the Dr. Beverly (as the Approved Provider) to share information with the Victim Advocate who might share information with the victim, Probation (the supervising criminal justice agency), the Court, and any other requested releases of information as deemed necessary by the Approved Provider;  6. You, as the Consumer agree to not violate criminal laws, statutes, or ordinances (city, county, state, or federal);  7. You, as the Consumer agree to comply with existing court orders regarding family support / child support;  8. You, as the Consumer agree to comply with any existing court orders concerning a Court proceeding to determine paternity, custody, the allocation of decision-making responsibility, parenting time, or support;  9. You, as the Consumer agree to not purchase or possess firearms or ammunition.  (An exception may be made if there is a specific court order expressly allowing the offender to possess firearms and ammunition.  You should speak with your attorney about this.)  In these cases, it is the offender’s responsibility to provide a copy of the court order to the Approved Provider to qualify for this modification of the Offender Contract. It is then the responsibility of the Approved Provider to design treatment planning to address storage of the firearm, (such as firearm shall not be allowed in the home) and other factors related to offender risk, safety planning, and victim safety;  10. You, as the Consumer agree to not participate in any couple’s counseling or family counseling while in offender treatment. This includes any joint counseling that involves the offender and the victim. *
Required

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.

 *
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. 2020, Dr. 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