Agreement for Participation
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Name: *
1. I agree or have agreed to 1 Intake sessions attend 24 education groups (1 ½ hours a week) and 1 individual exit session.

2. I understand that a requirement for participation in the Higher Hopes Counseling BIP Program includes talking about my use of violence and/or abusive behavior and accepting responsibility for it.

3.  I understand and agree to contact Higher Hopes Counseling if I will be absent and I must make up and pay for any missed groups.
4. I understand and agree that during the duration of the program I can only incur 4 absences (to include absences for non-payment).  I also understand and agree that on the 5th absence I will be automatically dismissed and all referral sources will be notified.
5. I understand and agree that I must pay for each session at the beginning of group (all fees will be taken from a card on file on the day of services/classes - cash is not accepted) or I may pay for all 24 group sessions at one time. However, in the event of being dismissed from the program, no refund will be issued. I also understand that if I do not pay the FULL group fee, I will not be allowed to stay in the group. I also understand and agree that this will count as an absence.
6. I understand and agree that Higher Hopes Counseling BIPP will contact my victim and /or partner to obtain a history of abuse and provide information about Higher Hopes Counseling resources that are available. Higher Hopes Counseling BIPP will provide my victim and /or partner with the name of my counselor. They may also be contacted periodically and will be informed of my completion or dismissal from the BIP program.
7. I understand and agree that on or about the 12th week of my group session, there will be a review session of my progress in the Battering Intervention Program.
8. I understand and agree that my financial obligation for Intake is $40.00 and classes are $25 per class and a fee reduction is not possible as per the TX CJAD Rules and Regulations for BIPP Services. I understand that this is a intake fee is one-time fee and will not be counted toward my group sessions. I understand that I must pay the $40.00 at the time of Intake and Orientation.
9. I understand and agree that after intake and orientation, I am assigned and agree to a specific group time and day each week. I understand and agree that if I do not show up for the first group that I will be automatically dropped from the program. If I come back within 30 days, I will have to pay the applicable fee of $25.00 to re-enroll. However, if it is more than 30 days, I will have to go through another intake and orientation and pay the full price of ($40). Therefore, it is strongly encouraged that you do not miss the first group.
10. I understand and agree that my financial obligation is $25.00 for each group for 24 weeks after the above start date.
12. I understand and agree that financial consequences are one way that I am being held accountable for my abusive behavior.

13. If I am hospitalized, I understand and agree that proof of hospitalization may result in an alternative absence schedule.

14. I understand and agree that if, after being dismissed from BIPP, if allowed by the program to re-start, I will re-start from week #1, regardless of the number of weeks I had when dismissed and no previously paid fees will carry over.  

15. I understand and agree that my being hospitalized and having proof (i.e. admittance and discharge papers) of said hospitalization is the only way to be Re-instated into the program.

16. I understand and agree that any reports of abuse, are grounds for automatic dismissal from Higher Hopes Counseling BIPP. I also understand and agree to follow federal firearm restrictions related to domestic violence offenses.

17. I understand and agree to notify Higher Hopes Counseling BIPP of any change of address or phone number.

18. I understand and agree to not disclose information disclosed in group outside of the group setting.

19. I understand agree that I am not allowed to record (via phone, recorder or any other electronic device) any group meetings, individual meetings, or any other meetings. This would result in an automatic dismissal. 

20. I AGREE NOT TO BE VIOLENT WITH ANY PERSON DURING MY PARTICIPATION IN BIPP.

By signing below I agree and understand this document. 

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