DVP Updated TPR #3
Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
Email
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example@example.com
1. What are your at least 3 SMART goals you want to continue to work on from treatment that impact your relationships?
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2. What therapist or agency (including medication management, if applicable) will you contact when you need support in the future? Who in your personal life will support you in the future?
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3. How are you demonstrating financial responsibility and why is this important?
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4. How will you take responsibility for ensuring safety for your children and family when there is a conflict?
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5. What are you currently doing to have productive arguments/conflicts? How will you make sure your partner feels safe in future conflicts?
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6. What are indicators of successful/unsuccessful stress management? Explain why it is important to know what your personal needs are.
7. How have you committed to eliminating the behavior that led you to the system? What tools/concepts do you use?
Therapist Comments (to be completed by clinician):
Treatment Changes/Recommendations (to be completed by clinician):
Client Signature
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Therapist Signature:
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