Qualities of Self and Partners in Relationships 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.
  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.

Worksheet Developed by Dr. Beverly (November 2022)
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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: *
What kind of person are you when you are in a Relationship? *
Never
Sometimes
Always
Industrious
Creative
Follower
Leader
Lover
Hater
Freaky
Straight Edge
Worker
Parent
Adult Child
Brutally Honest
Nice
Helper
Martyr
Very Serious
Jokester
Really Smart
Destructive
Neat-Freak
Slob
Collector
Hippie
Delicate
Durable
Dancer
Courageous
Narrow-Focused
Broad-Minded
Sex-Appeal
Passive
Aggressive
Straight Up
Religious / Spiritual
Daddy's Girl / Mama's Boy
Independent
Talented
Easy-Going
Futuristic
Frugal
Wasteful
Dwells on the Past
Forgiving
Humble
Fretful
Confident
Generous
Stingy
Punctual
Lackadaisical
Motivated
Waiting for to be told what to do
A Real Go-Getter
A Disappointment
Cheater
Attractive or Cute
Loyal
Political
Single-Minded
Foolish
Wise
Prideful
Lazy
Modest
What kind of person would you like to be with in a Relationship? *
Never
Sometimes
Always
Industrious
Creative
Follower
Leader
Lover
Hater
Freaky
Straight Edge
Worker
Parent
Brutally Honest
Nice
Helper
Martyr
Very Serious
Jokester
Really Smart
Destructive
Neat-Freak
Slob
Collector
Hippie
Delicate
Durable
Dancer
Courageous
Narrow-Focused
Broad-Minded
Sex-Appeal
Passive
Aggressive
Straight Up
Religious / Spiritual
Daddy's Girl / Mama's Boy
Independent
Talented
Easy-Going
Futuristic
Frugal
Wasteful
Dwells on the Past
Forgiving
Humble
Fretful
Confident
Generous
Stingy
Punctual
Lackadaisical
Motivated
Waiting for to be told what to do
A Real Go-Getter
A Disappointment
Cheater
Attractive or Cute
Loyal
Political
Single-Minded
Foolish
Wise
Prideful
Lazy
Modest
Why might it be helpful and even important to have a good idea of who you are and what you are like while in a Relationship? *
Why might it be helpful and even important to have a good idea of the type of person you would like to have as a Partner in a Relationship? *
How Helpful is Learning about the idea of working through: "Qualities of Self and Partners 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 Treatment impacted your Life? *
A Lot More Negatively than Positively Impacted.
A Lot More Positively than Negatively Impacted
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, 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.
 *
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)

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