DV Personal Change Plan and Aftercare Plan
Name
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First Name
Last Name
Email (a copy of this document will be sent to this address once you submit it):
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Probation Officer/Court Name:
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Triggers
What are your top five “button-pushers?” Label them low, medium, or high to determine how much each one affects you. What is your plan for dealing with them when they come up? If drug or alcohol abuse was part of your life leading to your offense, what are your triggers when it comes to use? Attach more paper as needed.
Internal/External Trigger, Red Flag #1 (include early warning signs). Be specific
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Level of effect of trigger #1
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Low
Medium
High
Plan/Tools to use to address trigger #1
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Internal/External Trigger, Red Flag #2 (include early warning signs). Be specific
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Level of effect of trigger #2
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Low
Medium
High
Plan/Tools to use to address trigger #2
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Internal/External Trigger, Red Flag #3 (include early warning signs). Be specific
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Level of effect of trigger #3
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Low
Medium
High
Plan/Tools to use to address trigger #3
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Thinking Errors (Cognitive Distortions)
Explain how your common thinking efforts (inaccurate/unhealthy thinking patterns) played a role in unhealthy relationship patterns and created disconnections in your relationship(s). Include at least 3.
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Think back to the offense:
1. What was the argument about?
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2. What were your thoughts at the time? Can you identify the thought that led to your abuse?
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3. What is a healthy, adaptive thought to oppose that cognitive distortion?
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Core Values
Core Value #1:
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How will you make sure your actions/behaviors support this value?
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Core Value #2:
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How will you make sure your actions/behaviors support this value?
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Core Value #3:
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How will you make sure your actions/behaviors support this value?
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Assertive Communication
What is assertive communication? Describe below how assertive communication could have been used in the situations that led to your offense.
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Identify the steps of a good time out:
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Cycle of Violence
Draw the Cycle of Violence:
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What tools or steps could prevent the cycle from repeating?
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At what point in the cycle do tools need to be put into action?
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Draw & Explain the 80/20/80 Concept:
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Describe how co-dependent patterns played a role in your offense and/or relationship:
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What steps will you take to make sure you have more healthy boundaries in the future?
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What are the different forms of abuse? Give examples of each. Which do you recognize from your own past relationships and how?
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Inter-generational Violence: How does violence get passed down from one generation to the next? What ways do you plan to change and stop this pattern from getting passed down to your children?
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What are the signs that show you are ready to complete treatment?
AFTERCARE PLAN
Who are the people, the agencies, the professional persons, or groups that will provide ongoing support and accountability for you when treatment is completed?
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Rows
Person/Group/Agency
Role They Play
1.
2.
3.
4.
5.
What steps will you take to get the support you need from your support system?
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What therapist or agency (including medication management if applicable) will you contact when you need support in the future?
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How are you demonstrating financial responsibility?
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How will you take responsibility for ensuring the safety of your children and/or family when there is conflict?
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Thinking back to your REPS statement, how you will you maintain your Plan? Include tools you will use and concepts you will use. List your options and be as specific as possible. Include any supports/mentors or other figures that will help you stay on track. If your incident included drugs or alcohol, include your sobriety plan. How have your perceptions changed? What have you learned?
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Thinking back to your REPS statement, how you will you maintain your Sustainability and Safety: What behaviors and thought patterns will you be on the lookout for which show that you might be sliding back into old ways? Be specific.
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How will you practice Mindfulness, Emotional Regulation, and Setting Boundaries?
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What was the most impactful thing that you took away from your treatment?
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Submit
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