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

Transform - Batterers Intervention Prevention Program (BIPP) Statement of Confidentiality & Consent for Treatment Confidentiality is defined as keeping private the information shared by you, the client, with your counselor. On occasion, other employees may need access to your record for agency teaching, supervision and administrative purposes. These staff members will also respect the privacy of your records. In accordance with the Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention & Prevention Program guidelines: Clients are required to sign Consent for Release of Information, which permits information to be released to the victim/partner and/or her designated representative, law enforcement, the courts, correction agencies and any others in accordance with agency policy.

As a client, you have the right to withhold or release information to other individuals or agencies. A statement signed by you is required before any information may be released to anyone outside Transform - BIPP. This right applies with the following exceptions: A. When a court of law subpoenas information shared by you with your counselor. B. When there is reasonable concern that harm may come to you or others, as in child abuse, elder abuse and abuse of a disabled person. In accordance to the Code of Ethics of the Texas State Boards of Licensed Professional Counselors, Chapter 681, Subchapter C, Rule 681.43:A licensee shall report to the Texas Department of Protective and Regulatory Services (TDPRS) if required by any of the following laws: 1) the Family Code, Chapter 261, concerning abuse or neglect of minors; 2) the Human Resources Code, Chapter 48, concerning abuse, neglect or exploitation of elderly or disabled persons. Also, when staff determines that there is probability of imminent physical injury to self or others, staff will take safety initiatives and may if appropriate, notify medical or law enforcement personnel and/or the victim/partner (Section 611.004 (a) of the Texas Health and Safety Code). C. When there is disclosure of sexual misconduct or sexual exploitation by a previous therapist or mental health professional. In accordance to the Code of Ethics of the Texas State Board of Licensed Professional Counselors, Chapter 681, Subchapter C, Rule 681.43

A licensee shall report if required by any of the following laws: 1) the Health and Safety Code, Chapter 161, Subchapter K, Rule 161.131 et seq.,concerning abuse, neglect and illegal, unprofessional or unethical conduct in an inpatient mental health facility, a chemical dependency facility or a hospital providing comprehensive medical rehabilitation services; and 2) the Civil Practice and remedies Code, 81.006, concerning sexual exploitation by a mental health service provider. 3) All personal data and possibly additional information will be submitted to TDCJ-CJAD by the program or provider for the purposes of performing program assessments and other research. 4) Media Involvement- Any media contact arranged by the Transform program or provider shall include the presence of a Transform employee to protect victim’s confidentiality.

We ask that you keep confidential information you may learn about other clients who are receiving services from Transform - BIPP.

Transform requires facilitators and participants to disable any devices that could collect information from the environment, such as Google Home Assistant, Amazon Alexa, or Apple Siri and sign an agreement that they will not record nor take screenshots of group. Transform requires each participant: is in a private space and not in any public area such as a park, yard, open area; other people not in the group should not be exposed to the content nor hear or observe the group. This includes changing locations, walking around the house, neighborhood, or any public space. • Responsibility of having a private area on the participant. • The participant cannot use virtual group session to expel his partner or children from the residence. • The participant must relocate to another location or private room in the residence. • For participants that are parents, Transform shall: discuss with participants how the participant will ensure children are safe and taken care of, but are not interrupting the session or listening to group discussions.

Ethics & Grievances: All agency services will be delivered in as professional and ethical manner as possible. It is impossible to guarantee any specific results regarding your goals. However, if you have concerns regarding the professional performance of your counselor, please inform your counselor. If your counselor is not able to resolve your concerns, please report them to your counselor’s immediate supervisor, CEO, Albert L. Chagoya, of Transform - BIPP.: 214-529-5644. If Mr. Chagoya is unable to resolve your concerns about professional performance, you may contact: Texas Council on Family Violence at 800.525.1978

I have read and understand the above statement and voluntarily enter into counseling services from the staff of Transform - BIPP- by entering my name, date of birth, and today’s date below:

Intake Information & Personal History

First name

Last name

Driver's Licence (or Identification) Number:

Home Address:

City:

State:

Zip Code:

Primary Phone: (Cell Phone Where We CAN Text You)

Email:

Date of Birth: required

Age:

Sex:

Employer:

Occupation: (what type of work do you perform?)

Military Services: (Branch & Date of Service)

Emergency Contact:

Emergency Contact Phone Number:

Referral Information

Probation/Parole/CPS Officer's Name:

Probation/Parole/CPS Officer's Email:

Probation/Parole/CPS Cause / ML Number:

Court Number:

Court Email:

Court Cause / ML Number

Attorney's Name:

Attorney's Email:

Attorney Court / ML Number:

Additional Charges or Arrests

Charge or Arrest Date:

Charges or Arrest Details:

Marital & Family Information

Name & Age of Children (if applicable):

Describe how you disciploine your children? Please provide example (if applicable):

Drug & Alcohol History

If YES, how often? and how much?

If YES, how often? and what drug?

Counseling History

If YES, please explain:

If YES, when was the last attempt?

If YES, what medications?

If YES, providing physician?

If YES to "head trauma", please describe:

Describe the most recent violent incident/offense/etc.: