Policy Comprehension and Agreement Form

BATTERING INTERVENTION AND PREVENTION PROGRAM

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1.  I understand that I will receive a copy of the PROGRAM OBLIGATIONS; I understand the obligations of the Higher Hopes Counseling Battering Intervention and Prevention Program. *

2.  I understand that I will receive a copy of the PARTICIPANTS OBLIGATIONS; I understand my participation obligations to the Higher Hopes Counseling Battering Intervention and Prevention Program.

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3.  I understand that I will receive a copy of the AGREEMENT FOR PARTICIPATION; I understand it and I agree to attend the HHC-BIPP Orientation on 

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4. I agree to attend the HHC-BIPP group sessions and understand that I will be given an start date once my intake session is complete:

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5.  I understand that I will receive a copy of the STATEMENT OF CONFIDENTIALITY; I have read and understand it.  I give consent for HHC staff to contact appropriate sources when there is the probability of imminent physical injury to myself or others. *
6.   I understand that I will receive a copy of the CONSENT FOR TREATMENT (Consent to Disclose to Court, Consent to Disclose to Partner, Consent to Media and Community Education, Participant Obligations and Consent); I understand my rights and responsibilities and agree to enter Higher Hopes Counseling Battering Intervention and Prevention Program. *

7.  I understand that I will receive a copy of the  CLIENT GRIEVEANCE POLICY; I have read and understand it.

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8. I understand that I will receive a copy of the GROUP RULES; I understand the Group Rules and consent to abide by them while a participant in the Higher Hopes Counseling Battering Intervention and Prevention Program.  I understand non-compliance with these terms may result in my dismissal from the program. *
Participant Name *
Date  *
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Agency Representative
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