Court-Ordered Domestic Violence/Anger Management Intake

Court-Ordered Services Only

This intake is for individuals who have been court-ordered to attend Domestic Violence, Impulse Control or Anger Management services.

If you were not court-ordered, please do not continue with this form.

--- CLIENT ACKNOWLEDGMENT ---

I attest that the above information is true and accurate.

--- CLIENT ACKNOWLEDGMENT ---

I attest that the above information is true and accurate.

--- CLIENT ACKNOWLEDGMENT ---

I attest that the above information is true and accurate.

--- CLIENT ACKNOWLEDGMENT ---

I attest that the above information is true and accurate.

GROUP RULES AGREEMENT

Group Rules are subject to revision at any time

1. Absences

Client acknowledges that they will be suspended on their 3rd unexcused absence and terminated on their 4th unexcused absence.

2. Payments

A sliding scale of payments is available for those who qualify. Otherwise:

•26 weeks of classes $35.00 per class ($910.00) + $45.00 Intake = Total $955.00

•52 weeks of classes $35.00 per class ($1,820.00) + $45.00 Intake = Total $1,865.00

If you pay half your balance within the first 30 days. We we zero out the other half!

Regular payment demonstrates integrity and responsibility for treatment. Attitude in class and timeliness also demonstrate integrity.

Payments to be made via Quickbooks invoice

3. Suspensions

If you are suspended (for lack of attendance, attitude, or behavior issues), you must go to Court Programs before being reinstated into the agency.

4. No Alcohol or Drugs

If alcohol or drugs were involved in your arrest or background:

•You will be scheduled for a Chemical Dependency Evaluation.

•You may be required to attend Chemical Dependency sessions.

•You may be subject to random drug and alcohol testing by the agency or the courts.

•You are required to pay for the test whether you pass or fail.

•If you fail the test, you will be suspended or discharged.

•If you decline the test, the agency will suspend you and notify the court.

5. Groups

Groups meet 1.5 hours per week on Zoom

You may not attend more than one group a week without a court order or you are making up a class

You must register for a specific group day

Zoom link will be emailed you after completing this form. Save a copy of zoom link in a secure place that is easily accessible 

6. Attendence roll call at begining and end of class

 Each week you must not leave early

•The first time you forget, the counselor will warn you.

•The second time, you will not receive credit.

•If you pay for a class and leave, you will be terminated.

7. Individual Appointments

A 30-minute Orientation appointment (included in the Intake fee) will be scheduled with a counselor (sometimes a Mental Health Evaluation may also be scheduled).

You must call by noon on the day of the appointment to reconfirm.

If you do not reconfirm:

•Your appointment will be canceled

•You will be charged

•Because you did not give 24-hour notice

The agency will not call you to reconfirm — it is your responsibility.

8. Confidentiality

What you hear in group must remain confidential.

Exceptions:

•Abuse of a child

•Abuse of an elder

•Suicide

•Murder

9. Lateness

If you are late, you will not be admitted

10. Class Behavior

 The following will result in suspension or discharge:

•Disruptive, racist, sexist, or argumentative behavior

•Use of “S” or “F” words (violent sexual reference)

 Additional rules:

•Wear appropriate attire

•Participate respectfully

•Ask non-argumentative questions only

•If you disagree with the answer, let it pass

•You are not here to teach

•Do not interrupt others

•Do not talk while others are talking

•Do not give advice unless asked

•Cameras on at all times

11. Class for Your Mate

Your mate may request a victim’s class to learn the intimacy skills you are learning.

12. Monthly Counselor Reports to the Court

 Your counselor must report monthly to the court regarding:

•Attendance

•Payments

•Behavior

•Class participation

If you pay attention, have good attitude, participate appropriately, and complete assignments, you will receive a good report.

If discharged for any reason, you may request reassignment to another program.

13. Status Reports for Court

Notify the front office 3 days-1 week prior to a court date so a Status Report can be prepared.

14. No Automatic Pass for

•Attending all sessions

•Paying in full

You must demonstrate that you learned and applied the skills

15. Disputes

If you have questions or problems with your treatment that the admin or counselor cannot answer, ask the program director.

--- CLIENT ACKNOWLEDGMENT ---

I agree to group rules

CONFIDENTIALITY NOTICE (NAC 228.160)

Nevada law requires that all domestic violence program participants receive and acknowledge the confidentiality provisions outlined in NAC 228.160.

A provider, supervisor of treatment, or staff member must not disclose any confidential communications made by the offender during the course of treatment except in the following situations:

1.With written consent of the offender

2.To report treatment status to the court that ordered participation

3.To comply with NAC 228.180 or NAC 228.195

4.During Division investigation or inspection

5.To notify a person at risk due to threats or dangerous behavior

6.To report child abuse or neglect

7.To report abuse/neglect/exploitation of an older person under NRS 200.5093

8.As otherwise required by law

--- CLIENT ACKNOWLEDGMENT ---

I acknowledge that I have been informed of the confidentiality provisions outlined above and consent to these conditions.

These rights include, but are not limited to, the following:

1.I have the right to confidential treatment.

2.I have the right to treatment appropriate to my needs.

3.I have the right to be treated with care and respect.

4.I have the right to be informed of the group rules.

5.I have the right to be informed of any services that might benefit me so that I may give my informed consent to such treatment.

6.I have the right to have my records transferred to another agency if I change agencies.

7.I have the right to be informed about my Treatment Plan.

8.I have the right to know the charges for my treatment ahead of time.

9.I have the right to an explanation for any charges I question.

--- CLIENT ACKNOWLEDGMENT ---

I acknowledge receiving a copy of this document

1. Authorization to Release Confidential Information

I hereby authorize this agency to release information from my records to the State Department of Prisons, District, Justice and Municipal Courts, the Public Defender’s Office and the District Attorney’s Office. I understand that this information may only be used by these agencies in their official duties regarding supervision over me. I further understand that this release is subject to Part 2, Title 41 of the Code of Federal Regulations. This consent terminates one year from the date of my signature.

2. Authorization to Release Confidential Information to a Third Party

I hereby authorize this agency to release information from my records to: Court.

I understand that this information may only be used by the above in their official duties regarding my treatment. I further understand that this release is subject to Part 2, Title 41 of the Code of Federal Regulations. This consent terminates one year from the date of my signature.

3. HIPAA Notice of Privacy Practices

I hereby acknowledge receiving a copy of the Notice of Privacy Practices.

This Notice may be changed from time to time. Contact us for any updated copies.

4. Non-Discrimination

I understand that this agency treats all clients equally and does not discriminate on grounds of a handicap, race, gender, religious affiliation, sexual orientation, national origin, or ability to pay for services.

--- CLIENT ACKNOWLEDGMENT ---

I acknowledge and agree to the above provisions.

A provider of treatment, a supervisor of treatment who is acting as a provider of treatment, or any other staff member of the program does not disclose any confidential communications made by an offender during the course of treatment or acquired through his or her work with the program as well as no staff member of the program discloses a confidential record or information contained in such a record to another person except:

a. Upon the written consent of the offender;

b. To the extent necessary to report the status of the treatment of an offender to the court that ordered the offender to participate in the program;

c. To the extent necessary to comply with the provisions of subsection 2 of NAC 228.180 or subsection 3 of NAC 228.195;

d. Pursuant to an investigation or on-site inspection by the Division;

e. To notify a person whom the provider of treatment believes may be at risk of imminent danger because of threats made or behavior exhibited by the offender;

f. To report evidence of child abuse or neglect to an agency which provides child welfare services or to a law enforcement agency;

g. To report evidence of abuse, neglect, exploitation, or isolation of an older person to an entity described in NRS 200.5093;

h. As otherwise required by law.

1. I acknowledge that I have turned over to this Domestic Violence Agency the order of the court requiring me to participate in a program.

2. I acknowledge that I have turned over to this Domestic Violence Agency any report concerning probation prepared by my parole and probation officer.

3. I acknowledge that I have turned over to this Domestic Violence Agency the results of any psychological evaluation of me.

4. I acknowledge that I have turned over to this Domestic Violence Agency copies of any medication prescriptions I am taking.

5. I agree to supply this Domestic Violence Agency with the victim’s name, phone and address, if requested, so this Domestic Violence Agency may check my version of the incident.

6. I agree to be free of all forms of violence including physical, verbal, psychological or sexual violence.

7. I agree to accept responsibility for my violent behavior.

8. I agree not to use sexist or racist language in the group counseling sessions.

9. I agree to pay all fees as agreed upon with this Domestic Violence Agency.

10. I agree not to use any alcohol or drugs while in this Domestic Violence Agency program if my evaluation shows that I have abused alcohol or drugs.

11. I agree to openly express feelings and emotions in the group counseling sessions.

12. I agree not to discuss the identity of or communications made by another offender in a group counseling session.

13. I agree not to violate a court order to avoid domestic violence, not to have contact with the victim if a court has ordered this, and to obey an order of the court to support my family and to obey any conditions of probation.

14. I agree not to have any contact with the victim who resides in a shelter.

15. I agree not to visit any shelter for victims of domesticviolence.

16. I agree to assist this Domestic Violence Agency in developing a Plan of Control and to follow it.

17. I agree to attend the number of treatment sessions ordered by the court and not to exceed four absences which will result in termination, referral back to the court and possible court sanctions.

18. I acknowledge that this Domestic Violence Agency will terminate me for violation of any of these provisions.

--- CLIENT ACKNOWLEDGMENT ---

I acknowledge and agree to the above provisions.