In Person TeeJuh Group Intervention Program

Today's Date

Date

Name

First NameLast Name

Age

Date of Birth

Date

Email

example@example.com

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have Health Insurance?

If you have Health Insurance, what is the name of the provider.

Military Experience:

Dates of Service:

Branch of Military

Type of Discharge:

Combat Experience:

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Social Security Number

Ethnic Group

Height:
Weight:
Hair Color:
Eye Color:

Tattoos (Location on Body)

Education (Highest Level Completed)

Place of Birth:

Raised:

Occupation:

Yearly Income:

Employer:

How long have you been at your current job?

Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you learn about our program?

Have you been to a Batterer's program before?

If yes, When?

Are you Court Ordered to a Batterer's program?

If yes, what is your case number?

Have you ever attended Anger management?

If Yes, how many time?

Do you have any pending cases?

If yes, when is your hearing date(s)?

Victim Name

First NameLast Name

Age

Date of Birth

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ethnic Group

Your relationship to the victim:

Are you and your victim living together?

Current Status:

Length of time in current relationship:

When did relationship begin:

When did you start living together:

Date of Marriage:

Date of Separation:

Date of Divorce:

Has your victim ever stayed at a Women's Shelter?

Has your victim ever received counseling?

Partner Name:

First NameLast Name

Age

Date of Birth

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Partner Phone number:

Please enter a valid phone number.

Ethnic Group

Are you and your partner living together?

Current Status:

Length of time in current relationship:

When did relationship begin:

When did you start living together:

Date of marriage:

Date of Separation:

Date of Divorce:

How would you describe your relationship?

Is your goal to remain in the relationship?

Has your partner ever stayed at a Woman's Shelter?

Has your partner ever received counseling?

Children's Informaton

	Name	Sex	DOB	Other Parents Name:
Child
Child
Child
Child

Do you think the children have been affected by the conflict at home?

Have your children witnessed any violence?

Relationship History

	Dates of Relationship	Length of Relationship	Present ages of children from this relationship	Who do these children live with now?
1
2
3

Was there any violence in any of these releationships?

If yes, please describe:

Date of Incident:

What happened:

Had you been drinking or using drugs at the time of this incident?

What type of injuries resulted from this incident?

When did you start using violence in this relationship?

Before Living TogetherAfter Living TogetherDuring Partners' Pregnancy

Date Started:

Describe the most violent incident that you have committed:

Have you ever done any emotional, physical, or sexual abuse in a previous relationship?

You were raised by:

Biological ParentsStep-ParentsOther Adult(s)

How would you describe your father (or the man who primarily raised you)?

How would you describe your mother (or the woman who primarily raised you)?

Did your mother drink during her pregnancy?

Who was primarily responsible for discipline?

How were you typically disciplined or punished?

What was the most severe punishment you received?

Do you have any siblings:

If yes, how many?

Looking back, do you consider yourself to have been:

	Yes	No	Not Sure
Punished Severely?
Punished Unfairly?
Physically Abused?
Emotionally Abused?

Please explain if you answered yes to the previous question:

Were you ever sexually abused during your childhood?

If yes, how old were you and who committed the abuse?

Did you ever see the people who raised you fight or argue?

	Never	Rarely	Sometimes	Often	Very Often
Respnse

When they argued, did they verbally abuse each other (call names, insult, use put-downs)?

	Never	Rarely	Sometimes	Often	Very Often
Respnse

Did you ever see or hear your father (or adult male) push, slap, or hit your mother?

	Never	Rarely	Sometimes	Often	Very Often
Respnse

Did you ever see or hear your mother (or adult female) push, slap, or hit your father?

	Never	Rarely	Sometimes	Often	Very Often
Respnse

Did you ever witness any other violence in the family or place you grew up in>

If yes, please explain:

Have you ever been arrested?

YesNo

If yes, please indicate the history of arrests below beginning with the most recent arrest:

	Date of Arrest	Charge	Sentence/Jail Term
1.
2.
3.

Any other domestic violence arrests?

YesNo

If yes, please indicate below:

	Charges	Date Occured
1.
2.
3.

Do you have any other assault charges?

YesNo

If yes, please explain:

How many times have the police been called to your house because of family disputes?

Are you currently on probation?

YesNo

If yes, for what charge?

Name of probation officer:

Is there currently a TRO (Temporary Restraining Order) in effect?

YesNo

Have you had previous restraining order with your current partner?

YesNo

If yes, how many?

Have you had any restraining orders with previous partners?

YesNo

If yes, how many?

Do you own or have any weapons?

YesNo

If yes, what kind?

Have you ever used weapons (or an object as a weapon) against your partner?

YesNo

If yes, please explain:

How often do you drink?

How many drinks to you typically have at a time?

When did you last drink?

Last time you were intoxicated?

Does it take more, less, or the same amount to get drunk?

Have you ever forgotten what happened during a period of time while you had been drinking (i.e. blackouts)?

YesNo

If yes, how many times?

Have you ever been arrested for DUI?

YesNo

If yes, how many times?

Any other alcohol-related arrests?

YesNo

If yes, for what?

Has drugs or alcohol use affected your job performance?

YesNo

Have you ever been fired from a job because of drugs or alcohol?

YesNo

Age of first Drink:

Age of first regular use of alcohol:

Is there a history of alcoholism in your family?

YesNo

If so, whom:

Do you use any other drugs?

YesNo

If yes, what kinds:

How frequently do you use them?

How much do you use each time?

Have you ever been arrested for a drug-related offense?

YesNo

If yes, when?

If yes, what was the offense?

Have you ever received treatment for drugs/alcohol abuse?

	Facility	Treatment Date
1.
2.
3.
4.

Do you ever get emotionally, physically, or sexually abusive when you drink/ use drugs?

YesNo

If yes, how?

Are you currently taking any prescription medications?

If yes, please specify:

Are you currently enrolled in any other types of counseling?

If yes, who are you seeing?

Have you ever been diagnosed with a mental illness?

If yes, please specify:

Have you recently thought of hurting yourself?

If yes, when?

If yes, what did you consider doing?

What stopped you?

Have you ever attempted suicide in the past?

If yes, please explain:

Any suicidal or homicidal ideations?

Any current feelings of depression or anxiety?

If yes, please explain:

Behavior Inventory: In this exercise, be honest and take time to consider each behavior on this list. If you have ever used it with a partner check the box next to that item.

	Yes	No
Raise hand
Block exit
Pull Hair
Scratch
Shake
Pinch
Push/Shove
Bruise
Throw Objects
Kick
Leave Bite Marks
Break bones
Burn/Scald
Restrain
Punch
Damage Face
Strangle/Choke
Blind/Deafen
Threaten With a Weapon
Cut/Stab
Beaten with Household Object
Shoot
Threaten to kill
Attempt to kill
Threaten Suicide
Abuse Pets
Get Partner Fiored from Job
Hit/Punch Walls or doors
Stalk or Follow
Threaten to injure/kill friends or family
Demand control of finances
Children present during fighting
Threaten to injure children
Chase with Vehicle
Drive Recklessly
Interrupt sleep/eating to continue arguing
Hurt Children
Verbal threats
Jealousy
Insult/put down
Disable Telephone
Threats of retaliation/revenge
Threaten to take children
Guilt Trips
Blame
Ignore
Shout/yell
Name Calling
Humiliate in public
Denial of money
Isolate from Friends/Family
Hurtful Jokes
Humiliate during sex
Compared to other sexually
Accused of Unfaithfulness
Unwated Fondling
Insluts: slut, whore
Children present during sex
Force partner to strip clothes
Give Sexual Diseases
Use Pornography
Injure breasts or genitals
Make her feel like an object during sex
Sex after violence
Demand Sex
Use objects during sex
Force to have sex with others
Force unwanted sexual behaviors
Make jokes about women as sex objects
Rape
Withhold sex or affection
Use threats to force sex
Criticize ability as a lover
Force partner to touch genitals
Cause pain to genitals during sex
Force to watch porn
Not allow use of birth control
Hit/Kick/Punch while pregnant

Alaska Screening Tool For Dual-Diagnosis and Traumatic Brain Injury Section 1: Please check YES or No to the following questions based on your activities over the past 12 months.

	Yes	No
1. Have you gotten into trouble at home, at school, or in the community, because of your drinking, using drugs, or inhalants?
2. Have you missed school or work because of using alcohol, drugs, or inhalants?
3. In the past year have you ever had 6 or more drinks at any one time?
4. Have you done harmful or risky things when you were high?
5. Do you think that you might have a problem with your drinking, drugs, or inhalant use?
6. When using alcohol, drugs, or inhalants have you done things without thinking, and wished you had not done them later?
7. Do you miss family activities, after-school activities, community events, traditional ceremonies, potlatches, or feasts because of your using alcohol, drugs, or inhalants?
8. Does anyone close to you worry or complain about your using alcohol, drugs or inhalants?
9. Have you hurt a friend or loved one because of your using alcohol, drugs or inhalants?
10. Do you use alcohol, drugs or inhalants to make you feel normal?
11. Does it make you mad if someone tells you that you are drinking or using drugs or inhalants too much?
12. Do you feel guilty about your alcohol, drug or inhalant use?
13. Do you or other people worry about the amount of money or time you spend at Bingo, pull- tabs, or other gambling activities?
14. Did your mother ever consume alcohol?
15. If yes, did she continue to drink during her pregnancy with you?

Section II: Please check YES or No to the following questions based on your activities over the past 12 months.

	Yes	No
1. Do you often have difficulty sitting still, paying attention at school, work or social settings?
2. Do disturbing thoughts that you can't get rid of ever come into your mind?
3. Do you ever hear voices or see things that other people tell you they don't see or hear?
4. Do you spend time thinking about hurting or killing yourself or anyone else?
5. Have you tried to hurt yourself or commit suicide?
6. Do you think people are out to get you and you have to watch your step?
7. Do you often find yourself in situations where you feel anxious and want to get away?
8. Do you sometimes have so much energy that your thoughts come quickly, jump from one
activity to another, you feel like you don't need sleep and like you can do anything?
9. Have you destroyed property or set a fire that caused damages?
10. Do you feel trapped, lonely, confused, lost, or hopeless about your future?
11. Do you feel dissatisfied with your life and relationships?
12. Do you have nightmares, flashbacks or unpleasant thoughts because of a terrible event like rape, domestic violence, incest/ unwanted touching, Warfare, a bad accident, fights, being or seeing someone shot or stabbed, knowing or seeing someone who has committed suicide, fire, or natural disasters like earthquake or flood?
13. Do you have difficulty sleeping or eating?
14. Have you physically harmed or threatened to harm an animal or person on purpose?
15. Have you lost interest or pleasure in school, work, friends, activities, or other things that you once cared about?
16. Do you feel angry and think about doing things that you know are wrong?
17. Do you often get into trouble because of breaking the rules?
18. Do you sometimes feel afraid, panicky, nervous or scared?
19. Do you feel sad or depressed much of the time?
20. Do you spend a lot of time thinking about your weight or how much you eat?

Have you ever had a blow to the head that was severe enough to make you lose consciousness?

If yes, when did it occur?

If yes, how long were you unconscious?

If Yes, how long did the concussion last?

If you had a blow to the head that caused unconsciousness or concussions, where there permanent changes to any of the following?

	Yes	No
Did not have a head injury.
Physical abilities
Ability to care for yourself
Speech
Hearing, Vision, or other senses
Ability to concentrate
Memory
Temper
Relationships with other
Ability to work or do school work
Use of alcohol or other drugs

Did you receive treatment for any of the things that changed after the head injury?

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.

Signature

Date

Client Services Plan
It is the policy of the TeeJuh Behavioral Health & Counseling Program that the following goals and objectives must be met in order to complete the program.

1. Committing no acts of physical or sexual violence for the duration of the program.

2. Attending, participating in, and completing homework for the 30-chapter curriculum.

3. Demonstrating satisfactory progress while in program.

I understand and agree that if I meet these requirements I will complete the TeeJuh Program. If at any time you become non-compliant with the program, an affidavit will be filed with the courts, you will lose credit for any classes you have completed up to that point, and you will be required to start the program over.
Your signature below indicates that you have read, understand, and agree with the above Client Service Plan of TeeJuh Behavioral Health & Counseling.

Your signature below, indicates that you have read, understand, and agree wit the above Client Service Plan.

Signature

Date

Men’s Group Absence Policy

The TeeJuh Group program allows 2 (two) unexcused absences without penalty during the 30 chapters that can take up to 33-40 weeks of class. The 3rd (third) unexcused absence will result in you being discharged from the program; an affidavit of non-compliance will be sent to the Court, the District Attorney’s Office, and other relevant agencies; and your victim/current partner will be notified as well.

The TeeJuh Behavioral Health Program is a 30-chapter class, you are required to attend/ complete all 30 chapters, regardless of unexcused/excused absences.

Your signature below indicates that you have read, understand, and agree with the Absence Policy of the TeeJuh Behavioral Health Program.

This Agreement contains important information about professional services and business policies. You will also see a document below titled, “Notice of Policies and Practices to Protect the Privacy of Your Health Information,” a notice required by the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). The law requires that your signature is obtained acknowledging that you have been provided with this information. By signing this document, you will be acknowledging that you have received the privacy notice and you will also be agreeing to the terms in this Agreement. You may revoke this Agreement at any time.

PSYCHOTHERAPY

Psychotherapy (also known as therapy or mental health counseling) is not easily described in general statements. It varies depending on the personalities of the therapist and client(s), and the particular issues you are addressing. There are different methods and interventions may be used to help address different issues. Psychotherapy is not like a typical health care provider visit. Instead, it calls for continuous active effort on your part. For therapy to be most successful, you will have to work in and outside of the sessions. Psychotherapy can have benefits and risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, shame, anger, frustration, loneliness, helplessness, and more. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Psychotherapy has also been shown to have many benefits. Psychotherapy often leads to improved relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees on what you will experience.

THE PROCESS OF THERAPY/EVALUATION

During the first few meetings, you will be assessed to determine if the therapist is a good fit for you and your needs. If deteremined to not be a good fit or benefit for your needs, you will be referred to others who work well with the issues you are requesting treatment for. Within a reasonable period of time after starting treatment, the understanding of your issues will be discussed, treatment plan proposed, therapeutic objectives, and possible outcomes of therapy. You will receive a clinical recommendation about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about the treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved. If during the work together it is assessed that the therapist can no longer be effective in helping you reach your therapeutic goals, they therapist will be obliged to discuss this with you and if appropriate, terminate treatment and give you referrals and recommendations who may be of help to you.

TERMINATION, TRANSITION, & FOLLOW-UP

Ideally stopping treatment is meant to be a mutual process. Before stopping treatment, it will discussed how you will know if or when to come back, or whether a regularly scheduled “check-in” might work best for you. It is recommended to have closure on the therapy process with at least two termination sessions.

Should you request to terminate and transition to a new therapist, your therapist is more than willing to talk with the therapist of your choice in an effort to aid the transition. Your therapist will to assist you in finding another qualified therapist with whom to consult if at any time you want another therapist’s professional opinion.

RECORD-KEEPING

Very brief records are kept, noting only that you have been here, diagnosis(es), interventions during session, and the minimum regarding the topics we discussed. If you prefer that no records are kept, you must give a written request to this effect for your file and it will only note that you attended therapy in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that any errors in your file be corrected. You have the right to request that 3 copies of your file are made available to any other health care provider at your written request. Your records are maintained in a secure location that cannot be accessed by anyone else. For more information about record-keeping see Notice of Privacy Practices below.

CONSULTATION

In order to provide you with the best possible care and service, your therapist may occasionally consult with other professionals regarding their clients. Names and other information which might identify people are never mentioned so that client anonymity and confidentiality is maintained.

CONTACTING

Due to the nature of the work as a therapist, your therapist may not immediately available by telephone. Phones will not be answered while in an appointment. When your therapist is unavailable, the phone is answered by confidential voice mail that is monitor frequently. Your therapist will make every effort to return your call on the same day, if not within 48 hours. If you find yourself in an urgent situation, make a judgment about the prudence of waiting for a call versus calling your primary care physician, 911, or your local 24-hour crisis line.

If you need to contact your therapist between sessions to alert them of an emergency, please call the office phone line at 1-877-935-6003. Your call will be returned as soon as possible. Voice messages are checked regularly, but with less frequency at night, on weekends, and on holidays, or during scheduled vacation time, about which your therapist will notify all clients of in advance.

If an emergency situation arises that requires immediate attention, call the emergency National Hopeline Network at 1-800-Suicide/1-800-784-2433 or the National Suicide Prevention Lifeline at 1-800-Talk/1-800-273-8255 or dial 911. Hearing and Speech Impaired should call 1-800-799-4TTY/1-800-799-4889. In the event of a life-threatening crisis please contact a crisis hotline, call 911, or go to a hospital emergency room.

CANCELLATIONS AND LATENESS

Missed and canceled sessions pose some issues for both of us. First, the work of psychotherapy is sometimes challenging and when we hit a difficult place together, sometimes it can feel easier to want to avoid coming in for treatment. Your therapist would prefer to speak about this with each other openly rather than canceling sessions. It is extremely difficult to fill canceled sessions on short notice. If you are running late for your appointment, please call or text as soon as you can to let your therapist know you will be late. If you are late for your session, your session will still end at the regular scheduled ending time. If you do not contact your therapist by 15 minutes into your session, it is assumed you do not plan to attend your session and your session time is forfeit.

CONFIDENTIALITY OF COMMUNICATION

Please be aware that e-mail, messaging using social media/internet messaging services, and text methods of communication are considered to lack the encryption necessary to ensure confidentiality according to HIPAA. Any electronic communication from these methods should be used only to set or verify appointments or for general “bookkeeping” issues. A secure, confidential messaging and email service through a HIPAA-compliant service provider is available upon request. Despite this, please always use caution when using communicating using the internet/phone service. Please do not contact via text or e-mail for emergencies.

INFORMED CONSENT FOR TELEMEDICINE/TELE-BEHAVIORAL HEALTH

Therapy conducted online is technical in nature and problems may occur with internet connectivity. Internet availability may be limited and disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction). Any problems with internet availability or connectivity are outside the control of your therapist. Your therapist makes no guarantee that such services will be available.

Disruption of video sessions due to technical complications can be resumed via telephone for the duration of the scheduled session time. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via telephone, a new appointment will be rescheduled. Please be aware that communication using a cell phone may not be secure and therefore not confidential.

Communication via www.zoom.com & the Zoom application are encrypted and HIPAA compliant. Emails sent from or to personal mail accounts are automatically secure. By signing this form you acknowledge and agree that all communication of a clinical nature should be sent via a HIPAA compliant method such as discussed during online therapy sessions or methods of being encrypted/confidential.

As a rule, clinical communications (i.e. communication for purposes other than scheduling) should be reserved for scheduled session time (in person face-to-face sessions, video sessions, phone sessions) except in cases of emergency. Your therapist will not respond to personal or clinical concerns via regular email, phone, or texting outside of your scheduled session time. Regular email nor text should not be used in the event of a crisis or an emergency.

Your therapist will not accept invitations to personal social media websites such as Facebook or Instagram, personal or professional networking websites such as LinkedIn, or instant messaging applications such as WhatsApp in order to maintain client confidentiality and privacy of all parties, and to maintain ethical and moral professional codes.

You are welcome to follow public social media platforms as the information provided is specifically for public use and access, such as Teejuh Behavioral Health on Facebook, Tiktok, and Instagram pages.

Online therapy is not a substitute for medication under the care of a psychiatrist or doctor.

Online therapy is not appropriate if you are experiencing a crisis, or having active suicidal or homicidal ideation with the intent to harm yourself or others.

Although substantial steps are taken to ensure the confidentiality and privacy of therapy provided online, your therapist cannot guarantee the security of any internet transmissions or communications. While your therapist takes active effort to assure privacy and continuously maintains awareness if there are other people in the room or area you are located, your therapist can not be liable for privacy when you allow others to be in the room without their knowledge.

Photos, Audio, and/or video recording sessions are NOT allowed. If you would like to take a picture or record a session, please discuss this with your therapist in advance. If mutually agreed upon, you may.

By signing this agreement you, the client, agree TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON YOUR OWN COMPUTER/MOBILE DEVICE AND IN MY OWN PHYSICAL LOCATION. You agree to never record or take pictures during therapy sessions. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

Email, phone, and text reminders may be automatically sent using the chosen electronic health records system. This consent includes understanding you may receive them unless otherwise noted. If you would like to opt out of reminders, please consult with the staff member providing services.

I certify and attest that the information is correct, to the best of my knowledge and belief. I understand I am agreeing and consenting to telemedicine/tele-behavioral health services if I choose to do so. I am signing that I have read and understood the Notice of Privacy Policies, provided below. I understand that falsification of information may subject me to denial of services.

Signature

Date

Notice of Privacy Practices- HIPAA Compliance - Required to Provide

Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record:

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We DO NOT charge a fee.

Ask us to correct your medical record:

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications:

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share:

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. (This does not apply as no payment for services is required.)

• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information:

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but DO NOT charge a fee if you ask for another one within 12 months. (Payment is not included as our services are no charge.)

Get a copy of this privacy notice:

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you:

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated:

• You can complain if you feel we have violated your rights by contacting us using the information above.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you:

• We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization:

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services: (Not applicable)

• We can use and share your health information to bill and get payment from health plans or other entities. (Not applicable)

Example: We give information about you to your health insurance plan so it will pay for your services. (Not applicable)

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues:

• We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research:

• We can use or share your information for health research.

Comply with the law:

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests:

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests:

• We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions:

• We can share health information about you in response to a court or administrative order, or in response to a subpoena

Our Responsiblities:

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing.

If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice:

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.

In Person TeeJuh Group Intervention Program

REFERRAL INFORMATION

Victim Information

Partner Information

CHILDREN'S INFORMATION

PREVIOUS RELATIONSHIP HISTORY

HISTORY OF ABUSE

CHILDHOOD/FAMILY HISTORY

LEGAL HISTORY

DRUG / ALCOHOL USE

Section III: Please check YES or No to the following questions on events in your lifetime.

Telemedicine/Tele-Behavioral Health Consent