Victim Information

Victim's Age?

If YES, how many children under the age of 18 live in the home?

If NO, how many children under the age of 18 are living with the victim?

Explanation Regarding Victim:

Victim's First Name:

Victim's Middle Name:

Victim's Last Name:

Home Address

City

State

Zip Code

Victim's Email:

Victim's Phone:

If all above "Victim Information" section is blank, check this box indicating you have no knowledge of the victim's address, email, phone number or any contact information; I hereby agree that this statement is factual and accurate by completing this signed document.

Consent for Disclosure of Information to Your Referral Source

I understand that such disclosure will be made for the purposes of information exchange, progress reports, coordination of services, other investigative departments and referrals and facilitating victim safety. Disclosure is limited to information regarding attendance, participation, information exchange, coordination of services and referrals & facilitating victim safety.

I understand that I may revoke this consent at any time and that my request for revocation must be in writing. If not earlier revoked, this consent for disclosure of information shall expire 1 year after completion of or termination from Transform - BIPP. I understand the right to confidentiality. I further understand that this consent form gives Transform - BIPP permission to share confidential information in the way described above.

Release of information is voluntary, I understand I have a right to refuse Transform - BIPP request for this disclosure. Transform - BIPP reserves the right to dismiss any client who refuses to meet the provisions of The Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention & Prevention Project guidelines.

Consent for Disclosure of Information for Partners

Current or Ex-Partner's Name:

I understand that such disclosure will be made for the purposes of progress reports, referrals and facilitating victim safety.

Disclosure is limited to information regarding attendance, participation, information exchange and referrals for services. I understand that I may revoke this consent at any time and that my request for revocation must be in writing. If not earlier revoked, this consent for disclosure of information shall expire 1 year after my completion of or termination from Transform - Batterers Intervention & Prevention Program.

I understand my right to confidentiality. I further understand that this consent form gives Transform - BIPP permission to share confidential information about me in the way described above. I understand that Victim will be contacted by the Victim Advocate and offered counseling services. She / He will be provided enrollment, completion or termination information from Transform - BIPP.

Release of information is voluntary, I understand I have a right to refuse Transform - BIPP request for this disclosure.

Transform - BIPP reserves the right to dismiss any client who refuses to meet the provisions of The Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention & Prevention Project guidelines. Information disclosed by batterers during an assessment (intake), group sessions, and exit is confidential and shall not be shared with victims.

Client Signature:

Today's Date required

Transform BIPP Orientation Intake Packet Completion

By clicking "Continue", I hereby confirm the above information to the best of my knowledge is correct and true, with no misleading or false content in accordance with Texas Perjury Statute, Sec. 37.02 (a) (2) Chapter 32, Civil Practice and Remedies Code.
This form will be printed and included in my client record. A copy may be emailed to me upon verbal or written request.

Transform BIPP Group: Batterers Intervention Prevention Program (BIPP) Statement of Confidentiality & Consent for Treatment - Continued

Victim Information

Consent for Disclosure of Information to Your Referral Source

Consent for Disclosure of Information for Partners

Transform BIPP Group: Batterers Intervention Prevention Program (BIPP)
Statement of Confidentiality & Consent for Treatment - Continued