Transform BIPP Group: Batterers Intervention Prevention Program (BIPP)
Statement of Confidentiality & Consent for Treatment - Part 2

First Name

Last Name

Fee per session is: Intake Orientation $50, $30 per group ($770 total). The fee isonly one type of demonstration of your accountability and restitution for violent behavior. Breaks, Assessmets (Intake), Orientation, or Exit Sessions are not included towards the 36 hours (24 Weeks).

Batteing Intervention andPrevention Program consist of Assessment (Intake) and Orientation and at least 36 hours of group sessions in a minimum of 24 weekly sessions. Not to exceed one session per week. If dismissed, client must apply to re-enter into Transform BIPP. Re-entry is considered on a case by case basis. I understand that I cannot re-enter the program until I have paid off my previous balance.

Clients who miss (3) consecutive sessions (group or individual) or a (total of 5 sessions), you will be discharged from the program. Your referral sources will determine what happens with your case as a result of your absences. *There are no excused absences. Incarceration is an inexcusable absence. Clients have the option to attend “Attendance Review” if client is facing discharge.

You must be focused and facing your webcam during the entire group; NO watching TV or working on your computer; You will only be given one warning, second warning will result in no credit for the session and/or receive a discharge violation from Transform BIPP program.

You must be in a quiet room; not driving, in your car, or doing any other activity, otherwise you will receive no credit for that BIPP session and/or receive a discharge violation from Transform BIPP Program.

If there is any interruption during your Transform Group by a child or adult, you will lose credit for your class and/or receive a discharge violation from Transform Program.

If there is any appearance of alcohol, or vaping during Transform Group, it will result in a request for a drug test, if found dirty, you must sign a behavioral contract or unsuccessfully discharge from Transform BIPP Program.

During your Transform Group, ifthere is any woman present even for a moment, especially the victim, you shall receive no credit for the class and/or be unsuccessfully discharged from Transform BIPP Program.

If after a restroom break you do not return, or you take more than 5 minutes, you shall receive no credit for your Transform BIPP Group session.

Payment for services is due at the time service is rendered. You will not be credited for attending groups or individual sessions unless payment is received. Client is required to maintain no more than a $30 balance. I will continue to attend until I have a zero balance. Attendance may exceed 24 weeks if payment is not completed.

I hereby agree to arrive to all of my sessions on time. If you are 5 minutes late after the designated start time - you will not receive credit for attending group.

I understand that I must register into group upon online login with group facilitator. I will not be counted present for the session unless I register in with group facilitator.

I will notify Transform BIPP of any change of address or phone number.

I hereby agree to cntact BIPP by phone at 214-529-5644 when I am unable to attend a scheduled session. Failure to contact Transform within 2 consecutive absences is an automatic discharge from Transfrom Program.

I agree not to attend group under the influence of alcohol or drugs; refusal of a Drug Screening is an automatic discharge. It will be my responsibility to arrange transportation home or any safety measures so I'm not a danger to myself or others for driving under the influence. The referring agency will be notified of the incident.

I hereby agree not to be abusive towards any staff person or other group member. I understand that I may not use sexist or racist language.

I hereby agree to respect the confidentiality rights of my fellow client/group members. I further understand that a violation of this rule shall result in immediate termination from the program and shall be reported to the proper authorities.

I hereby agree to notify a staff person of any and all emergencies that I am either part of or witness to.

I understand that Transform BIPP is committed to helping me gain a better understanding of my problems and how to find productive solutions and that it is the main goal of my psycho educational classes.

During group discussions, participants may not blame anyone else for their own behaviors.

Participants agree to not use any form of violence, abusive, threatening and controlling behaviors including stalking during the weeks they are in the program. A participant who uses violence may be terminated from the program. This action will be reported to participant’s referral agencies. Participants will cease violent, abusive, threatening, and controlling behaviors, including stalking and violation of a protective order. Participants who are terminated for this reason and wish to re-enter to the program will re-start from 1st week.

Participants will develop and adhere to a non-violence plan as outlined in program curriculum.

Transform Group requires me to disable any devices that could collect information from the environment, such as Google Home Assistant, Amazon Alexa, or Apple Siri and I agree that I will not record nor take screenshots of group. Transform Group requires me to be: 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. The responsibility of having a private area is mine. I cannot use virtual group session to expel my partner or children from the residence. I must relocate to another location or private room in the residence. If I am a parent, I agree to ensure my children are safe and taken care of, but are not interrupting the session or listening to group discussions.

Individualized Plan

Choose your reason(s) for attending the Battering Intervention & Prevention Program (BIPP): Required

Other:

Describe the reason why you are here? (Offense)

Client's Personal Goal for Attending BIPP:

EXAMPLE:
Objective:

Client will increase his knowledge regarding the issue of abuse, domestic violence and skills that can help him change behaviors and eliminate abuse and violence from his relationships.

Strategies:

Client will attend the BIPP group weekly for 90 minutes and will participate actively and display receptiveness to the information presented.
Client will make consistent application of skills presented by thinking about the new information presented, reviewing the handouts, talking about what he’s learning with others, asking questions, making application of skills, completing assigned homework, giving examples in group of the progress he is making and by only focusing on him and his relationship with his partner.
Client will practice POSITIVE SELF-TALK by stating I DON’T ARGUE, I DON’T FIGHT AND IF NEEDED I TAKE A TIME-OUT SO THAT I KEEP ME AND MY FAMILY MEMBERS SAFE FROM ABUSE AND VIOLENCE.

In the event that you are deemed inappropriate for battering intervention and prevention program services. Transform - Staff will make recommendations to the referral source for additional services or treatment. Clients with severe mental health problems such as chronic depression, personality disorders, or suicidal or homicidal ideation), disruptive behavior, substance abuse problems, and/or generalized violence may not be appropriate for the program and should be referred back to the referral source.

Battering Intervention & Prevention Program Clients & Terminology Policy

I have received a copy of the "Policy for Clients" for Transform - BIPP. I understan my rights and responsibilities and I agree to enter Transform - BIPP.

I understand that in accordance with Guideline 31 of the Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention Prevention Program guidelines, I am being provided a written agreement that clearly delineates the obligation of the Transform - BIPP to the client. I understand that the Transform - BIPP shall: 1. Provide services in a manner that I can understand. 2. Provide copies of all written agreements. 3. Notify me of changes in group time and schedules. 4. Comply with anti-discrimination laws. 5. Report quarterly to probation, courts of law, and/or other referral agencies regarding my progress or lack of progress during group. 6. Provide reports weekly and/or monthly about my BIPP progress to my referral source: Probation, Parole, Child Protective Services, Courts, Attorney. 7. Report to me regarding my status and participation. 8. Provide fair and humane treatment.

As a client of Transform - BIPP you have the right to terminate services with our agency at any moment. The risk of terminating services will be explained to you by a counselor/instructor. You have the right to choose other agencies for your services and Transform - BIPP will provide you with a list of known community agencies that may provide the services you need, except for clients referred by Probation; clients will be referred back to their Supervision Officer.

Transform - BIPP also has the right to terminate services with clients if : A. Continued abuse, particularly physical violence. B. Client has accumulated (3) consecutive absences or a total of (5) sessions. C. Client has failed to pay for services over $30 dollars E. Client is believed to be violent/aggressive towards others or staff. F. Client is involved in illegal activities on the premises. G. Client need for treatment is incompatible with types of services H. Free for Life-BIPP Client violates any of the BIPP rules. I. A report will be made within 5 working days to your referral source of any known law violations, incidents or physical violence, and /or termination from BIPP. J. Clients have the right to seek other resources outside of Transform - BIPP and when possible Transform - BIPP staff will provide or make a referral.

The above Termination Policy applies to clients who are attending services on a Voluntary basis or Court-ordered to receive services or who are mandated to receive services by other entities; however, clients are responsible to check with those entities who mandate them to come regarding the alternatives for receiving services in another agency or consequences for choosing to stop services before making this final decision.

Transform - BIPP will provide batterers at the time of assessment (intake) with a copy of the circumstances under which they can be terminated before completion.

Case Notes

Date: required

File Number:

Cause Number:

Counselor:

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 - Part 2

Individualized Plan

EXAMPLE: Objective:

Client will increase his knowledge regarding the issue of abuse, domestic violence and skills that can help him change behaviors and eliminate abuse and violence from his relationships.