Abuser Intervention Program Registration / Online Intake Consent

Name

First NameLast Name

Date of Birth

Assigned gender at birth:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

I am requesting an intake because I am:

I understand and agree to the following:

I must provide my name, phone number, address, and email address so that the agency can contact me to schedule a virtual intake. I consent to have the agency contact me via email, phone, or mail.

I will pay the intake fee of $65.00 via the Pay Now link at https://www.sarc-maryland.org/get-help/abuser-intervention-program/ to complete my registration. I understand this fee is non-refundable.

I understand that if I miss this appointment without giving notice 24 hours in advance, I will forfeit this fee. To be accepted into the program I will then have to reschedule and submit an additional $65.00 for the rescheduled intake appointment.

I understand that if I have been previously terminated from the Abuser Intervention Program at SARC, I must pay in full any remaining balance in order to be eligible to re-enroll. I understand that to re-enroll I must also provide a referral signed by my Probation Agent or an updated Court Order (if applicable).

I will provide the following documents for my intake as requested: photo ID, proof of income or unemployment, and Court Order, Statement of Charges, or Protective Order (if applicable). I understand that I will not be able to complete the intake process without providing the requested items.

I will provide accurate contact information for the identified victim, and agree to allow the agency to contact the victim per program requirements.

I understand that any threats or threatening behavior, verbal, physical, or sexual in nature, as well as any demeaning or derogatory comments directed towards victims, other group members, or SARC staff is grounds for immediate termination.

I understand that all SARC and AIP staff are mandatory reporters of child abuse and neglect, elder adult abuse and neglect, and will contact the appropriate person(s) should I make statements about harming myself or another.

I understand that by choosing to enroll in SARCs AIP, I am subject to all policies and program rules, and that these may be updated or changed during my time in the program. I understand that participating in the program indicates I agree to all program rules and any future changes to the rules that may occur while I am enrolled.

The following are authorized to receive information regarding my involvement in the intake process for SARC’s Abuser Intervention Program:

Select all that apply:

If alternate, please specify:

Probation / Parole Agent Name or DSS/DHS Caseworker Name:

I am choosing to participate in a virtual intake via Zoom. By choosing this option, I understand that I must use a computer, tablet, or smartphone with video and audio ability, in a space with privacy, free of interruptions, and with a strong Wifi or data signal.

SARC has made every reasonable effort to implement technical security measures that reduce risks of a confidentiality breach. I understand the risk and I agree that SARC and my facilitator should not be held responsible if any outside party gains access to our zoom group.

Signature and Date