Enrollment Application – DV Group

Victim Information

California Penal Code and Los Angeles County Probation Department require Domestic Violence programs to attempt to notify the victims regarding the requirements for the defendant’s participation in the batterer’s program. The disclosure of this information is required as part of your Probation terms.

Financial Information

Individuals on formal or summary probation under California PC 1203.097 are expected to pay a fee for their participation in the Batterers’ Intervention Program. Completion of this form is required for all applicants upon enrollment or when submitting a fee evaluation form. It is used to assess your ability to pay the agency fees based on disposable household income and available resources. Providing misleading or false information may result in denial or termination of service.

Service Agreement - DV Group

All clients on formal or summary probation under California PC 1203.097 are required to attend consecutive 2-hour long weekly sessions at a rate of one session per week until the completion of 52 sessions. The program must be completed in a period not exceeding 18 months. Probation terms allow you to have up to THREE (3) EXCUSED ABSENCES for the entire year. A FOURTH (4th ) ABSENCE will result in your immediate termination and referral back to court/probation. In that event, you will have to submit authorization to re-enroll from the referring agency in order to be readmitted to the program. All clients will be dismissed from the program for missing 3 consecutive sessions. If you are on probation and need an extended absence, you must request authorization from the referring agency and submit it to our office before your leave to avoid dismissal.

You are responsible for being on time for every meeting. There is NO GRACE PERIOD. If you arrive later than your scheduled starting time, you will be marked “Late”. You will be marked “Absent” after the third late session. If you arrive more than 5 MINUTES late, you WILL NOT be allowed to join the group and you will be marked absent and charged for the missed session. This will be determined only by the time of your arrival and not by the reason for which you were late. Work, traffic or any other reasons will not be considered excuses for arriving late. Calling the office will not excuse you from this responsibility.

Once session begins, you may not leave your meeting until your counselor dismisses the group for the day. There are no breaks in between. If, for any reason, you leave or are asked to leave your meeting before its conclusion, you will be marked “Absent.”

You may not attend any other group other than the one assigned to you, unless authorized by the administration. Authorization for a make-up session must be requested by calling the office during our business hours. A make-up session can only be used to compensate for a missed session and not to double up to accelerate the program. Make-up sessions will be approved based on availability and the number of incurred absences at the time. A make-up session will only help you regain lost time for a missed session; it will not replace your regular meeting, nor will it clear the absence from your attendance record.

Enrollment and re-enrollment fees are administrative processing dues and are non-refundable. The fees for service are indicated below under Consent.

Fees for services are due and payable at the time services are rendered. Payment for in-person sessions must be received at the beginning of each meeting in the form of cash only. Payments for telehealth sessions can be made with credit / debit card through electronic invoices sent to you ahead of time by email or by text. Additionally, you may mail a check or money order, or pay cash at our office during our normal business hours. While enrolled in the program, you are responsible for paying said fee every week for your scheduled day and time, WHETHER YOU ATTEND OR NOT. Group sessions cannot be cancelled or rescheduled. When absent, payment for the day/s you were absent must be made in full upon returning to session.

There will be a $25 additional administrative charge for any check returned unpaid by the bank. Your counselor will issue up to one (1) standard progress report per month to each referring agency free of charge. You will be billed for any additional work at a prorated rate of $120 per hour, this includes but is not limited to additional reports during a month, and phone calls in excess of 5 minutes in one (1) week, whether initiated by you or a third- party involved in your case.

If you are unable to continue to make payments, you can call the office to make financial arrangements or to discontinue the program to avoid further charges to your account. Completion reports or transfers will not be issued until any outstanding debt has been paid in full. In the presence of a balance, one session will be deducted from your attendance for each unpaid week on any progress report. If your account becomes delinquent and is not paid after 120 days, and arrangements for payment have not been agreed upon, Advantage Counseling Services may use legal means to secure payment.

You are required to maintain all communications and information obtained while participating in the program confidential. You may not disclose any information obtained during group sessions regarding other participants in the program, including all conversations, events, and identities of other participants. A violation of the terms of confidentiality will result in removal from the program.

All communications between you and your counselor will be held in strict confidence unless you provide written permission to release information about all or part of the information about your counseling to a specific person or agency. Your counselor may not be subpoenaed to testify in court proceedings.

There are, however, certain legal exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder/dependent adult abuse. Therapists may be required to break confidentiality when they have determined that a client presents a serious danger of physical violence to another person or when a client is dangerous to him or herself.

For clients who are on summary or formal probation, probation conditions under California PC 1203.097 and Los Angeles County Probation Department require program to contact the victim and current partner to provide them with information about the client’s participation in the program. This information includes signed contracts, program contents and guidelines, case and program status. Probation conditions also waive the client’s confidentiality on all information obtain by the program in order to assess compliance with the counseling program and the terms and conditions of probation. Progress reports stating your attendance, progress, and compliance with the program will be issued regularly to the referring agency. Additionally, there may be occasions when Probation Department monitors are present during group sessions, or where the group is video/audio recorded for program evaluation purposes.

While enrolled in the program, you are required to comply with all court orders, probation/parole conditions, and protective/restraining orders, if any. Additionally, you adhere to any recommendations or referrals to collateral programs such as drug or alcohol treatment. It is mandatory to provide the program with the correct address and phone number of the victim and promptly notify the program of any changes. You are required to stop the use of any violent or threatening behavior, and adhere to any weapons prohibitions. Violation of any protective/restraining order or any further threats or acts of domestic violence reported to our office will result in your referral back to court/probation. You are responsible to informing our office about changes regarding your current case, probation officer, future court hearings, protective orders, new arrests, new/pending charges, and personal and victim information such as name, phone number, email, and address changes.

You are required to attend sessions free of chemical influence. If you are suspected to be under the influence of drugs or alcohol, you will be asked to leave the meeting, and a violation report will be sent to the referring agency. Smoking, as well as the consumption of drinks, snacks, and gum chewing, is not permitted during sessions. If you carry a cellular phone, it is mandatory to turn off the ringer.

Physical contact and the use of improper, obscene, threatening, racist, or sexist language are strictly prohibited during session or while dealing with the agency staff. You are required to follow the instructions given by counselors or staff members, actively participate during group discussions, including sharing personal experiences, values, and attitudes, and complete all group activities and assignments. Administrative issues will not be discussed during group time. If you have questions about fees/balance, attendance, schedule conflicts, or any other concerns, please call or visit the office during our business hours outside your session time.

If you are found in violation of any of the terms of this agreement or if it is determined that you are disruptive, uncooperative, or not benefiting from counseling, you will be asked to leave the meeting and may be terminated from the program. If, at any time during your participation in the program, you become unable to comply with any of the terms of this agreement, it is your responsibility to notify the administration to make arrangements or request termination from the program.

I acknowledge receipt of a copy of the terms of the program and the online program rules, the 52-week program content, the definition of domestic violence, alternative techniques to violence, and a receipt for payment.

Online Program Rules - DV Group

In order to participate in our on-line program, you are responsible for ensuring you have the appropriate hardware, software, and reliable internet connection to access the meetings.

You must attend the meetings regularly once a week. If you miss three (3) consecutive sessions, you will be discontinued from the program. If you are discontinued and wish to return to the program, you must contact the administration and pay the re-enrollment fee to be readmitted. If you have a criminal court case, you will also need to obtain a re-enrollment order from the court or probation officer to be re-admitted.

Payments for session must be received no later than 15 minutes before the scheduled meeting time to allow time for processing and to have your name added to the upcoming group roster. Payments received after this deadline may not processed in time to allow you to join the meeting. No payments will be processed after the meeting start time. If you need to make payment arrangements, you must call the administration in advance. If you have provided us an email address or cellular phone number, we will send you an electronic invoice that can be paid online using any debit or credit card. Electronic invoices are normally sent days in advanced to provide ample time for payment. Alternatively, cash payments can be made at the office.

You must be logged-in to the video conferencing platform by the scheduled meeting time. After this time, you will not be admitted to the session; there is NO GRACE PERIOD. When logging in, you must use your FIRST and LAST NAME so that you can be easily identified by the counselor in order to be admitted.

To protect the confidentiality of all members, your meeting location must be and remain private for the entire duration of the session. You are required to be alone or to have a wall behind you as your background and use headphones. Children under 2 years old should not be present. If in a parked vehicle, you must be alone and with good lighting. You may not be driving or be a passenger in a car.

Your camera must remain on for the entire meeting. You must have good lighting and be seen clearly. You must remain sitting up in front of the camera; your full face to the top of the shoulders must be in view for the entire duration of the meeting. Face masks, filters of digital backgrounds are not allowed.

Although this is an online meeting, it is expected that you conduct yourself as if you were in person. No walking, smoking, cooking, eating, chewing gum, lying down, watching TV, or using electronic devices. You must remain fully engaged and actively participate in the discussions.

You must stay logged in for the entire duration of the meeting to receive credit for a session. If for technical reasons you lose your connection, you can try to reconnect within a 5-minute window. Reconnection attempts after this time will not be allowed, and you will not receive credit for the session, regardless of the time your connection was lost. If you are removed from the meeting by your counselor, you will not be allowed to reconnect on that day, and you will not receive credit for the session.

Here are examples of situations that will result in your removal from the group:

• Not having your camera on.
• Not being in front of the camera.
• Not participating appropriately, being distracted or engaged in other tasks, or not answering when called on by the counselor.
• Not being in a private setting, or being in a car driving or as a passenger.
• Talking to somebody else around you, or the indication of the presence of any additional person/s around you.
• Being disrespectful toward the counselor or other members.

You may call the office and leave a message for your counselor at any time. Counselors are not available to answer calls or receive messages while the group is in progress.

If you need a progress report, you must provide the court date or report due date with at least 3 business days’ notice. Progress reports are typically available for pick up at the office after the last scheduled session before they are due. If this timing does not suit your schedule, please make alternative arrangements with your counselor or the administration in advance.

I have read and understood the above online program rules, and agree to all of the terms.

Authorization to Release Confidential Information - DV Group

I hereby auhorize and request Advantage Counseling Services to release and obtain any and all necessary confidential information, including, but not limited to, personal records, progress in treatment, summary of treatment, dates of treatment, diagnosis, summary and results of psychological testing, summary and results of psychiatric evaluations, results of investigations, and court and police reports to/from the person or organization listed below:

This following section applies to client on formal or summary probation under CA Penal Code 1203.097:

I authorize the free exchange of information between prior batterers’ programs, collateral treatment programs, and all relevant legal entities, including criminal, juvenile and civil courts, police departments, Parole, Probation, District Attorney’s Office, Department of Children and Family Services, Adult Protective Services, Family Court Services, Office of Pre-Trial Services and any other entity that the court may specifically direct, the victim, and any victim advocacy or support agency.

I authorize the release of the information described above for the purpose of managing services, coordinating services, and verifying compliance with any orders or recommendations for counseling.

I understand that I can revoke or modify this authorization, with written notice, at any time, except to the extent that action has already been taken in reliance upon it. Unless revoked earlier, this authorization shall be valid for five (5) years after the termination of services.

I understand that my signature below authorizes the release of the confidential information described above and that this information may not be re-released to any other entity or individual without my additional signed consent unless otherwise provided by law. I authorize the use of a duplicate copy of this authorization as having the same legal effect and validity as the original. I furthermore release Advantage Counseling Services of all liability resulting from the release of information while this authorization is in effect.

Intake Questionnaire - DV Group