I, {name} voluntarily enter into this agreement with TeeJuh Behavioral Health and Counseling for all staff to provide me with treatment services. I understand and agree to the following:
My violence/abusive behavior is either documented in police records or self-assessed as a problem (or both). I agree that in order to participate in the treatment programs it is necessary for me to talk openly about my violence/abuse.
I will use no physical or sexual violence while I am in the program, or make terroristic threats.
I will not be violent or abusive in my treatment group or individual treatment sessions.
I will advise the TeeJuh program of all biological and adoptive children, provide TeeJuh with a copy of any court or administrative order that requires child support payment, comply with requests for information or cooperation with any agency enforcing child support payment, provide documentation of payment and child support payments, and sign a release to allow TeeJuh to obtain child support payment records if requested.
TeedJuh will make Safety Checks: contacting my present and past partners, spouses, and dependents. These will occur throughout the treatment program and may continue for 1 year after completing treatment.
I will keep confidential names or information about other persons attending the TeeJuh program other than myself to any other persons or agencies other than TeeJuh. I will not violate confidentiality.
I will adhere to contracts and agreements regarding payment of child support / court-ordered costs and program fees.
I will not miss more than two scheduled sessions, classes, groups, etc. in a seven-month period without a valid reason. Valid reasons include court dates, attorney or OCS visits, or other events out of my control. These missed classes will not count towards my two allowed absences and I agree to present homework in the next group.
I will comply with all the conditions of my treatment plan. It may be stated as part of the treatment plan to successfully complete other groups or classes not held by TeeJuh.
I will not participate in couples or relationship counseling unit I have been free from violence and coercive behavior for a minimum of six months.
I will make continual treatment progress, as measured by staff/professional opinion.
I will attend the group reasonably groomed and dressed.
Throughout the duration of this program, I will disclose to TeeJuh any violations of this contract.
Failure to comply with any of the above points may lead to my termination from the group. A notice of termination will be forwarded to the victim/current partner and the following agencies: (Adult Parole/Probation; State, Federal,Local Courts; OCS, etc.)
Sessions may be observed by other TeeJuh staff, or persons, who have a legitimate interest in observing treatment meetings for training purposes. No session will be observed without prior notice to you. Any observer will sign consent to confidentiality.
As outlined by the Department of Health and Human Services Regulations (42 CRF Part 2) no disclosure of a client/patient's record can be compelled unless permitted by the regulations, or after obtaining written consent. (This does not apply in a case where physical or sexual abuse or neglect of a child or vulnerable adult has been disclosed, know where intent to harm self or others has been disclosed).
TeeJuh is required by the estate to immediately disclose the following information to the program participant's victim, current partner, sentencing court, probation/parole and law enforcement, and if appropriate local victim agency): Any threats or actual destruction of property; threats to violate, attempts to violate, or violation of child custody or child visitation orders; and threats of physical harm or actual physical harm or any person or pet.