My Control Log Worksheet
  Please complete and submit this Worksheet in order to successfully meet the requirements of 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.
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  Please respond to the following items Truthfully and Thoughtfully.

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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? *
Scenario:  Think about the conflict that you had with your current or previous partner that got you this DV Offense.  Answer the following questions:
Who was Involved?   *
What was the Problem as I saw it -- on the face of it right at that time?   *
Actions: Describe the actions that I was using to either try and control the situation or my partner?   *
Intents: What was I intending to happen?   *
What did I want (or need) to happen at that time?   *
Beliefs: What beliefs did I have that helped me support my Intents and my Actions?   *
What was I believing at the time -- that seemed to justify my actions?   *
Feelings: What feelings was I having at the time?   *
Minimization, Denial and Blame:  In what ways was I minimizing or denying may actions, or trying to blame them on someone else?   *
Effects: 1. What was the Impact of my actions on me? *
Effects: 2. What was the Impact of my actions on my Partner or the Victim? *
Effects: 3. What was the Impact of my actions on others? *
Past Violence:  1. What was the Impact of past violence on me? *
Past Violence:  2. What was the Impact of past violence on my partner or my victim? *
Non-Controlling Behaviors: What are some examples of some non-Controlling Behaviors that I could have used instead? *
STATEMENT OF HUMILITY: In what ways are you culpable for what happened here?  What did I do wrong here? *
STATEMENT OF ACCOUNTABILITY: Write a one-sentence Statement of Accountability about this situation?   *
PREVENTION: How could you prevent this in the future? *
In any given situation involving you and your partner; how much Control do you have over the entire situation? *
No Control At All
Total Control
How Helpful is Learning about Making a Control Log 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? *
I hereby affirm that I am aware that paying for my DV Treatment is a significant part of demonstrating that I am making progress in my Treatment. I am also aware that if I am not making payments at least every two weeks, and if I have a balance due of more than $70 at any time, I can be suspended from DV Treatment and/or Discharged as Unsuccessful without further notice. * *
Required
I hereby affirm that I it is up to me to try and compute the Balance that I owe to my Provider for my Treatment. I understand that given that the weekly session fee is $35, that I do not have to wait for a Balance in order to start making payments for the Services I am receiving. I am also aware of how I can make payments; either through using a Card or Online Payment App using the links on the Blog; or through mailing payments to my Provider. I also understand that it is my responsibility to start the process of paying for my DV Treatment immediately. And I agree that if do not start making regular payments, I can be Discharged Unsuccessfully from this Treatment without further notice. * *
Required
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