Community Chest Inc. Intake Form

Perpetrator Information and Description

By signing below I am stating that I am a victim of violence requesting assistance for services to alleviate family violence factors. The above information is true to the best of my knowledge.

Limited English Proficiency Line: 1-800-522-SAFE (up to 150 languages spoken)

The information presented here is important for you to read and understand. If you have any questions about this material or about your treatment, please ask you Advocate. In order to participate in case management here, you will need to sign (at the end) indicating you have read and understood this information.

What you say to us here is confidential. This means we will not divulge the content of your communication to anyone other than the staff here at Community Chest, those for whom you have signed a release, or certain others when we are required to do So by law. As indicated, we may release information about you when legally required, as, for example if you have harmed or threatened to harm yourself or another, in a medical emergency, if you tell us of child or elder abuse, if we are compelled by a court of law, or you give us written consent. You may also participate in group services here, and others in the group will get to know you. We ask you and all group members to not share any information about those in your group with anyone but your therapist and others in your group. This is to protect your confidentiality. However, we cannot guarantee these confidences will be kept.

VAWA Section 3: Confidentiality Provision "A) In GENERAL. In order to ensure the safety of adult, youth, and child victims of domestic violence, dating violence, sexual assault, or stalking, and their families, grantees and subgrantees under this title shall protect the confidentiality and privacy of persons receiving services.

(B) NONDISCLOSURE.-Subject to subparagraphs (C) and (D), grantees and subgrantees shall not:

(1) disclose, reveal or release any personally identifying information or individual information collected in connection with services requested, utilized, or denied through grantees' and sub- grantees' programs, regardless of whether the information has been encoded, encrypted, hashed or otherwise protected; or (ii) disclose, reveal, or release individual client information without the informed, written, reasonably time-limited consent of the person (or in the case of an unemancipated minor, the minor and the parent or guardian or in the case of legal incapacity, a courtappointed guardian) about whom information is sought, whether for this program or any other Federal, State, Tribal or territorial grant program, except that consent for release may not be given by the abuser of the minor, incapacitated person, or the abuser of the other parent of the minor, (C)RELEASE. - If release of information described in subparagraph (B) is compelled by statutory or court mandate -(i) grantees and subgrantees shall make reasonable attempts to provide notice to victims affected by the disclosure of information; and (ii) grantees and subgrantees shall take steps necessary to protect the privacy and safety of the persons affected by the release of the information. (D) INFORMATION SHARING.-(1) Grantees and subgrantees may share- (1) nonpersonally identifying data in the aggregate regarding services to their clients and non-personally identifying demographic information in order to comply with Federal, State, tribal, or territorial reporting, evaluation, or data collection requirements, (II) courtgenerated information and law- enforcement generated information contained in secure, governmental registries for protection order enforcement purposes; and (III) law enforcement-and prosecution-generated information necessary for law enforcement and prosecution purposes (ii) In no circumstances may 0 an adult, youth, or child victim of domestic violence, dating violence, sexual assault, or stalking be required to provide a consent to release his or her personally identifying information as a condition of eligibility for the services provided by the grantee or subgrantee; (II) any personally identifying information be shared in order to comply with Federal, Tribal, or State reporting, evaluation, or data collection requirements, whether for this program or any other Federal, Tribal or State grant program."

In order for us to provide you with the highest quality of care, we may need to talk with other professionals you have seen. We therefore may ask you to sign a "release of information" allowing two-way communication about you to these professionals. These may include, for example, physicians, therapists, probation officers, lawyers or your insurance company if you wish them to pay part of your bill. We may also request a release of information to a family member when appropriate.

While we are usually in the office during regular business hours, we will be unavailable to talk to you on the telephone while meeting with a client and after normal business hours (weekends, holidays, and vacation periods When we are unavailable, you may leave a message at 775-847- 9311. We will make every effort to return your call within 72 hours with the exception of weekends and holidays. When leaving a message, please inform of when you are available along with a contact number.

If you are in crisis or have an emergency situation and you are unable to connect with an advocate your signature below acknowledges your agreement to call 911, contact the Crisis Call Center at 775-784-8090, or proceed to the nearest hospital emergency room. If the emergency situation occurs outside of the business hours of Monday through Friday, 9am-5pm, as client you are also provided access to our mental health after-hours suicide hotline at 775-297-1267. For vicrtims of crime and emergency line is provided and cqaan be utliszed 24 hours a day, 7 days a week at  775-720-0007.

We pride ourselves in having quality programs run by highly competent professionals. Your advocate is available to you for the purpose of court accompaniment, assistance with filling out paperwork, and other general case management services. Our goal is to provide support to you as you obtain the resources you need in order to be successful.

ADVOCATE AND CLIENT RESPONSIBILITIES

As a participant in the advocacy process, you will be expected to come consistently and promptly to your appointments. It is your right and your responsibility to choose to continue or discontinue services at any time. It is also possible that your advocate may decide to end services because of consistent missing of appointments, disrupting the services of others, or we believe you could be served better elsewhere. In the latter case, we will give you names of a few other places where you may continue to seek services. We are not the only place you can receive services, and it is up to you to choose the place you prefer. You may also choose not to seek services at all. Client identifying information will not be used for any research purposes.

Occasionally problems will come up while receiving services. We encourage you to speak to your advocate about anything, and if she or he cannot help you, she or he will direct you to the appropriate person. If for some other reason you do not feel comfortable continuing with the advocate you are seeing, we will discuss this with our staff and recommend one of two options. We might suggest that you continue with your advocate, or that you seek services at another program of your choosing or one we might recommend. If you wish to file a complaint, please contact Adrienne Sutherland, Clinical Director, at 775- 847-9311, ext. 201.

To cancel or reschedule counseling sessions without receiving a charge for the cancelled appointment, generally you will need to call Community Chest at (775) 847-9311 at least 24 hours before your scheduled appointment.

I have read this informed consent and have asked questions about any parts that were unclear to me. I now fully understand and agree to the conditions stated herein.

Community Chest Inc. Family Violence Department Safety Plan

This safety plan is for victims of domestic violence. Safety planning helps develop tools in advance of potentially dangerous situations. Although I do not have control over my partner's violence, I do have a choice about how to respond to him/her and how to best get myself and my child/children to safety. Choose only the suggestions listed here that make sense for your set of circumstances.

Have a safe place to stay. Make sure it is a place that can protect you, your children and grandchildren. You should have at least two locations you can go already decided should you leave. Find someone you trust. Leave money, extra keys, copies of important documents and clothing with them in advance, SO you can leave quickly, if necessary. Have a packed bag ready. Keep it hidden in a handy place in order to leave quickly, or leave the bag elsewhere if your abuser finds your location. Call a domestic violence victim service program. Find out which services and shelters are available as options if you need them. Keep their address and phone number close at hand at all times. Trust your judgment. Consider anything that you feel will keep you safe and give you time to figure out what to do next. Sometimes it is best to flee, sometimes to placate the abuser - anything that works to protect yourself and the children. Devise a code word or signal. This is a precaution to have in case the abuser arrives at your safe place. Tell your children or neighbors SO you can communicate to them that you need the police. Change all account information. Consider changing all utilities into your name only, along with your cell phone account, and bank account. Consider changing your cell phone number also, to elevate the abuser from having contact with you. Have a safety plan. Teach your children or grandchildren how to call the police or someone they can trust. Have a secret code word that you and your children agree on - to communicate trouble and for the people who are allowed to pick the children up.

Checklist of important items to have: Marriage and driver's licenses Birth certificates - yours and families Money, checkbooks, credit cards, ATM cards, mortgage payment book, car title Social Security card and passport Divorce, custody papers and restraining order Insurance papers and medical records Lease, rental agreement and/or house deed School and health records Keys - house, car, office, friends Medications, glasses, hearing aids, etc., needed by you and your family Personal items - address book, pictures, toys Copies or your intimate partner's green card and social security card Benefit card, food stamps Immigration Documents Upgrade your security system. Change the locks on all doors and windows as soon as possible. Consider a security service, better lighting, smoke detectors and fire extinguishers. Talk to neighbors and landlord. Inform them that the abuser no longer lives with you and that they should call the police if they see the abuser near your home. Get legal advice. Find a lawyer knowledgeable about domestic violence to explore custody, visitation and divorce provisions that protect you and your children. Discuss getting a restraining order as an option. Keep your Order of Protection with you at all times.

Exchange child/children in a safe place. Find a safe place to exchange the children for visitation. Some communities have specific locations just for this purpose.

Let them know who has permission to pick up the children and give them your code word. Discuss with them the other special provisions to protect you and your children. Provide a picture of the abuser if possible. Give photocopies of your Order of Protection to your children's school and childcare provider.

Decide whom at work you will inform of your situation, especially if you have an Order of Protections. This may include office security if available. Provide a picture of the abuser if possible. It is your right to request and expect confidentiality from those you disclose to. Create a safety plan for when you enter and leave your work. Have someone escort you to your vehicle or other transportation.