I   First Name   Last Name   agree to participate in an intake evaluation with a staff member, trainee or outreach worker of the Berkeley Community Violence Intervention Program. I understand that records concerning my intake and program registration will be maintained and retained in confidence. Such information will be kept confidential according to the CA Welfare and Institution Code Section WIC 14184.102. No information about me will be released to other agencies or persons outside of the City of Berkeley and BCVI program staff without my written consent, except permitted by law, including the following exceptions:

BCVI staff are compelled by law to inform an appropriate other person(s) and/or agencies if they hear and believe that you are in danger of hurting yourself or someone else, and if there is reasonable suspicion that a child, dependent adult, and/or elder adult has been abused.

I understand that this intake evaluation is not a guarantee of support from BCVI.

I understand that my case will be discussed by the BCVI staff and a suitable disposition, either to BCVI or another provider, will be made.

Furthermore, I understand that once I am accepted support from the BCVI team, that there may be a waiting period before I am assigned to a life coach, case management or resources. During this waiting period, I understand that my intake contact will regularly update me regarding my intake status and start date if accepted into programming.

I am aware that I can call my intake contact at any time for questions regarding engagement or if I change my mind about entering engagement with

I also understand that if I fall out of contact with my intake and/or registration outreach worker, they may look for me. This may involve using contact information I have provided to call, write, and/or visit me or other people I have named who know how to reach me.

I understand that this intake contact will respect my advance wishes about what types of contact are acceptable.

I have read the above statement, understand, and agree to these service terms.