SafeHaven PAIP — Completion Form

Client Personal Email

Please explain any personal goals you have set for yourself to remain non-violent

Please explain how you plan to use the lessons learned in group in your present and/or future relationships

Detail concrete steps that you plan to take during conflict to remain non-violent

How do you feel about your participation in this program?

Electronic Signature

By writing your name below, you are acknowledging this document.

URICA-DV-R Attitudes and Behaviors Survey

Survey Directions: This survey asks a lot of questions about violence. By "violence," we mean physical aggression toward a partner or ex-partner, like a wife or girlfriend. This includes throwing objects, pushing, slapping, kicking, or choking, using a weapon, and other behaviors that can cause fear, pain, or injury. If you did none of these things, think about "violence" as the thing you did that got you arrested or got you into a domestic violence program. By "ending the violence," we mean using healthy strategies to improve your relationship and stay violence-free. Examples of healthy strategies include: communicating with your partner clearly and respectfully; managing stress; controlling your anger; and, not abusing drugs or alcohol. Please tell us how much you DISAGREE or AGREE with each of the following statements. Base your answers on how you're feeling and acting NOW.

Individualized Exit & Non-Violence Plan