DVI Assessment Informed Consent

I understand the purpose and process of the Domestic Violence Inventory (DVI) Assessment and have been provided the opportunity to ask questions. I understand that my participation in this assessment is voluntary and that I may refuse or withdraw my consent at any time.

I hereby consent to participate in a Domestic Violence Inventory (DVI) Assessment using the following primary assessment instrument: the Domestic Violence Inventory (DVI). I understand that secondary measurement tools may also be administered as clinically appropriate, which may include the TAAD-5, GAD-7, Burns Depression Inventory, DSM-5 Cross-Cutting Symptom Measure, SASSI-4, ACES, Personality Inventory for DSM-5 – Brief Form (PID-5-BF), and the Novaco Anger Scale.

I understand that the results of this assessment may be used to develop recommendations for services based on the assessment findings.

I agree to provide complete, accurate, and truthful information to the best of my knowledge.     

As a participant in Step Three Inc.’s Batterers Intervention Program, including the completion of the DVI Assessment, you have the following rights: 

(a)  Each client shall be afforded all constitutional and statutory rights of all citizens of the State of Oklahoma and the United States, unless abridged through due process of law by a court of competent jurisdiction.  Each program shall ensure each client has the rights which are listed below: 

(1) Each client has the right to be treated with respect and dignity. This shall be construed to protect and promote human dignity and respect for individual dignity.

 (2) Each client has the right to receive services without regard to his or her race, sex, color, age, national origin, genetic information, religion, disability, or legal status. 

(3) Each client has the right to refuse to participate in any research project or medical experiment without informed consent of the client, as defined by law. A refusal to participate shall not affect the services available to the client.

 (4) Each client has the right to assert grievances with respect to any alleged infringement of these stated rights of clients, or any other subsequently statutorily granted rights.

 (5) No client shall ever be retaliated against, or subject to, any adverse conditions or services solely or partially because of having asserted the rights as stated in this section. 

(6) Each client has the right to know why services are refused and can expect an explanation concerning the reason he or she was refused certain services.

 (b) Each client shall be given a copy of these rights and the provision of such shall be documented in the client record. 

 

If you believe your rights have been violated contact: 

ODMHSAS: Office of Consumer Advocacy, E-Mail: AdvocacyDivision@odmhsas.org 

Local: (405) 248-9037 Toll Free: (866) 699-6605  Reachout Hotline (800) 522-9054 

My signature below indicates that I have read and understand my rights as outlined in this document and that I have been offered a copy. 

 A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights. Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation upon request at no expense.

No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights. As stated above, the consumer has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for person and/or property and will not be subjected to discrimination or reprisal for so doing. 

If the consumer feels that he or she has a grievance, he/she can complete a grievance orally or in writing with Step Three, Inc. He or she has the right to seek a review thereof with the Director.  A memorandum of the grievance will also be made by the Director. 

The grievance should specify any objections or disagreements which the consumer has of Step Three, Inc. Every attempt will be made to resolve the grievance. Should the grievance be resolved, a written report of the actions to alleviate the aggrieved will be provided to the aggrieved consumer. Should the aggrieved consumer not be satisfied with the resolution, the grievance shall be forwarded to the Board of Directors by the Director, with staff recommendations for resolution. In any event, the recommended resolution shall be provided to the aggrieved patient within one week of receiving the written grievance. 

In addition to the above, the consumer also has a right to file a grievance with or without the knowledge of Step Three, Inc, or its staff, to the Office of the Office of Consumber Advocacy either telephonically or in writing.  

No adverse consequences or reprisals will be experienced by any persons filing a grievance or complaint against Step Three, Inc.   

ODMHSAS: Office of Consumer Advocacy, E-Mail: AdvocacyDivision@odmhsas.org 

Local: (405) 248-9037 Toll Free: (866) 699-6605  Reachout Hotline (800) 522-9054 

My signature indicates I have read and understand my rights to file a grievance and have been offered a copy of this document.

 

I acknowledge that I am choosing to participate in a DVI assessment.  I understand that the results of this assessment will not have the same level of confidentiality afforded by mental health services. I acknowledge and understand that the assessment results may be shared with the following parties:

Judge, District Attorney, or referring agency
Current partner
The victim(s)
Parent of any of my children
Probation and Parole
Law Enforcement
Anyone toward whom there is a risk of imminent harm by me
Coordinated Community Response Team
The domestic violence victim service program

 

I understand that Step Three, Inc.

 will promise confidentiality with respect to the general public, news media, and anyone else not covered in the expectations set forth above.