DAPS Group Registration Form

DAPS Group Registration

Registration Form
Name:

First NameLast Name
DOB:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Ethnicity/Race (Choose all that apply):

Other
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship:
How were you referred to DAPS?

Other
Have you been involved with DAPS before?
Are you on probation?
How long is your probation?
Probation Officer Name:

First NameLast Name
Is there an order of protection against you?

Rows	Yes	No
Have you been to counseling?
Do you have a history of abusing alcohol?
Do you have a history of abusing illegal substances?
Have you ever had a chemical dependency assessment?
Have you ever been to chemical dependency treatment?
Did you complete treatment?

Please describe in detail what has brought you to work with DAPS:

What are some things you’ve done in the past to improve yourself as a partner?
What positive changes would you like to make for yourself?
What might happen if you don’t make changes? Short term and long term.

DAPS FEE POLICY:

The fee for participation in the Men's Responsible Relationships: Accountability & Education Program is $600. This covers the required workbook and 14 weeks/40 hours of curriculum. The $600 fee must be paid prior to starting groups.

These fees are non-refundable regardless of attendance or other circumstances that may arise. If you are suspended and wish to restart the program, DAPS will require you reenroll and pay costs in full for reinstatement after suspension from the program.

1. You will be suspended for any unexcused abscense, regardless of reason and maximum abscenses is 2, also regardless of reason.

2. You will be suspended for misconduct in class that continues after it has been addressed or prior to it being addressed if staff feel that your misconduct is too severe to allow you to continue.

Payment can be made directly to DAPS via cash, credit card or debit card. If you choose to pay with a credit or debit card, a 3.5% electronic fee will be administered to the total cost of the program.

By signing my name, I am agreeing that I've read, fully understand and agree to DAPS fee policy.
Name

First NameLast Name
Date

MonthDayYear
Date

CONTRACT FOR PARTICIPATION
- I understand that a requirement for participation in the DAPS program includes talking about my behavior in detail and accepting responsibility for it.
- I understand that there is a non refundable tuition fee of $600 for the program. If you are suspended for any reason, the full fee will be due at each reinstatement.
- I agree to attend 14 classes at 2 hours per class and to complete all assigned homework. I acknowledge there is a 2 missed class maximum to prevent suspension and that homework is required to complete the course.
- I agree to contact DAPS if my contact information changes.
- I understand that if my attendance is court ordered, my facilitators will report my attendance, any concerning actions, and an evaluation of my progress to Probation/Parole, Child and Family Services and/or other community members for which a release of information form has been obtained. Any violations of Conditions of Probation or Civil Protection Orders are grounds for suspensions or termination from class and referral back to court.
- I agree to notify DAPS of any police contact, service of a protection order or any new or pending charges.
- I understand that DAPS is required to report any suspected acts of child abuse or neglect, any concern for my safety or the safety of others or reports of further violence.
- I agree not to attend DAPS under the influence of any drugs and/or alcohol. I realize that by doing so, I will be suspended from services and my probation/parole officer will be immediately notified.
- I agree not to use violence with any person during my participation in the DAPS nonviolence education program.
BY TYPING MY NAME BELOW, I AGREE THAT I'VE FULLY READ, UNDERSTAND AND AGREE TO THE PARTICIPATION POLICY AS WELL AS THE CONTRACT FOR PARTICIPATION.
First NameLast Name
DATE OF SIGNATURE

MonthDayYear
Date

AUTHORIZATION TO RELEASE AND RECEIVE INFORMATION

I authorize DAPS, its staff, agents, and affiliated providers to release to and receive from the referring or governing entity listed below any information related to my participation in services.

Referring or Governing Entities May Include:

• Felony Probation
• Missoula Justice Court
• Missoula Misdemeanor Probation
• Missoula Pre-Trial Services
• Missoula District Court
• Missoula Municipal Court
• Missoula Correctional Services
• State of Montana Probation and Parole
• Court representatives in the county in which my case resides

This authorization permits two-way communication between DAPS and the above-listed entities for purposes of monitoring compliance, coordinating services, and reporting progress.

I understand that the following information may be exchanged:

My attendance and participation
Any use of violence or threats of violence
Reasons for suspension or termination from programming
Recommendations regarding changes in programming
Information regarding progress, concerns, and level of engagement
Any information regarding current drug or alcohol use
Any information regarding contact with a protected party when a no contact order is in place

I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance upon it.

This authorization shall remain valid for the duration of my participation in services with DAPS and any period of court or probation supervision related to this referral, unless revoked earlier in writing.
BY TYPING MY NAME BELOW, I AGREE THAT I UNDERSTAND AND AGREE TO THE PROGRAM FEE AND PARTICIPATION POLICY AS WELL AS THE CONTRACT FOR PARTICIPATION.
First NameLast Name
Date

MonthDayYear
Date

DAPS Program Acknowledgment Statement:

DAPS provides a non-therapeutic, educational intervention program. This group is designed to address accountability, behavior change, and relationship dynamics.I understand that I am not receiving psychotherapy, counseling, medical treatment, or mental health services through this program.I acknowledge that participation in this group does not establish a therapist-client relationship and is not in any way a substitute for individual mental health or substance use treatment.

BY SIGNING BELOW, I AGREE THAT I'VE FULLY READ, UNDERSTAND AND AGREE WITH DAPS PROGRAM ACKNOWLEDGMENT STATEMENT:
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: