Victim Empathy - Intimate Partner & Family Agency Commitment Form

Moving forward, what choices might be better in the future?

Consider what I’m upset about and how I want to address it

Step back to calm down and think

Set clear personal boundaries for myself [Do not “name call”; Do not become physical]

Plan ahead on how to handle conflict or anger

Talk about what bothers me earlier to avoid explosive arguments

Stay accountable for my actions - Apologize if I might have hurt someone’s feelings; Listen to others, repeating back to them or validating that I hear them; Consider their feelings

Focus on my actions and my responsibility, regardless of others’

Refuse to turn to alcohol when upset or angry

Talk things out when everyone is sober and calm

Find ways to communicate or express myself differently

Journal or take time to self-reflect

Find constructive or useful alternatives to fighting

Identify the issues that are causing your feelings or conflict (Jealousy, work stress, money stress, etc.)

Address one issue at a time

Be willing to compromise

Other - what are your ideas?Other - what are your ideas?

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors; this document does not reflect any admission or denial of any prior action.

Explain three ways you commit to reducing Intimate Partner and Family conflict for yourself: *

Explain three ways you commit to reducing risk for your family, friends, neighbors or community: *

Signature *

/s/

please sign with your full name

Date

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Victim Empathy – Intimate Partner & Family Agency Commitment Form

Victim Empathy – Intimate Partner & Family Agency Commitment Form

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors; this document does not reflect any admission or denial of any prior action.

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