My Experiences of Equality in This Relationship
  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.

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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?) *
Please complete this Worksheet regarding the Relationship you were in when you got your DV Offense:  How many years  (or months) were you involved in this relationship?  Please specify the number of years or months, as well as whether it is in years or months: *
Were the two of you married to each other? *
How satisfied were you with this relationship at the point when you got your DV Offense? *
Not Satisfied
Very Satisfied
How satisfied do you feel that your partner was with this relationship at the point when you got your DV Offense? *
Not Satisfied
Very Satisfied
What is the likelihood that you and your partner will be together one year from now? *
Not Likely
Very Likely
Please describe how you and/or your partner experience(d) Non-threatening Behavior in your relationship: *
Please describe how you and/or your partner experience(d) Respect in your relationship: *
Please describe how you and/or your partner experience(d) Trust and Support in your relationship: *
Please describe how you and/or your partner experience(d) Honestly and Accountability  in your relationship: *
Please describe how you and/or your partner experience(d) Responsible Parenting in your relationship: *
Please describe how you and/or your partner experience(d) Shared Responsibility in your relationship: *
Please describe how you and/or your partner experience(d) Economic Partnership in your relationship: *
Please describe how you and/or your partner experience(d) Negotiation and Fairness in your relationship: *
Please rate each of the following characteristics of Equality as per how present this characteristic is (or was) in this relationship? *
Not Very Present
Cannot Recall
Very Present
Non-threatening Behaviors
Respect
Trust and Support
Honestly and Accountability
Responsible Parenting
Shared Responsibility
Economic Partnership
Negotiation and Fairness
If your partner were here right now, how accurate would she or he say that your above responses are? *
Not Accurate
Very Accurate
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?) *
Please click next to the "Yes, I Agree" button below in order to confirm that you are aware and that you Agree that you are responsible for paying for your DV Treatment in a timely manner.  Also note that if anyone goes too long without making payments on their account, they can and will quite possibly be discharged from Treatment as Unsuccessful.  You are also acknowledging that you understand and agree to the following:  (All DV Clients need to pay their IOU's ASAP!  There is no need to ask Dr. B for your Balance.  You can track this yourself (see below).  All you do is follow these simple steps:   1. Multiply the number of Sessions that you have attended by $35 each.   2. Then Subtract the amount of any paid Vouchers (Your P.O. or Dr. B. can help you with that info).   3. After that, Subtract any payments we have already made.   4. Then, you can Pay the Remaining Balance using the PayPal Button to the Right of this Page.  Just Click on the Picture Above; Or, simply Go to one of the PAYPAL LINKs on the BLOG to pay right now!   5. If you cannot pay it all off at one time; please just pay the $35 every week (Cash, Card or Voucher), PLUS an extra $25 or some other amount to go toward your Balance until it is paid off.   Thank you.   *
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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?    (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. 2021, Dr. Beverly))
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