Contract for Participation in DVIP

Contract for Participation in DVIP
Name__________________________ date__________
Court Ordered______ Volunteer ____
______I understand I am enrolling in the DVIP______ or the Ace_____ Program.
______I agree to attend group sessions on _______ from at the YWCA. I will begin groups on _______________ and agree to attend ______ groups.
______I understand that I cannot miss more than ______ group sessions. The only excused absences are a death in the family or a health emergency. The absence must be verified by the proper authorities. If I miss more I will be terminated, have to start over, will not get credit for classes attended up to my termination, and pay any outstanding fees I may owe.
______I understand I will not be allowed into group if I am more than 5 minutes late
______I understand I will not be allowed into group if it is suspected I have been drinking or using drugs 24 hours before group, and I will not get credit for the group.
_____I understand DVIP will report to referring agencies, if any, my attendance or my termination.
______I agree not to be violent with anyone during my participation in group sessions. Any violent acts, verbal or physical will be reported and I will be terminated from the program.
______I will refer to my partner or victim by their first name. I will respect the facilitator and others in the group. If I disrespect anyone while in group, I will be asked to leave and not receive credit for that group.
I understand I must pay $________ each week and will not get behind. If I am behind in my payments, I will not be allowed to stay in group. I must call Janet Boudreau at 810-238-7621 ext. 309 before I am allowed back into group.

_____I understand if I leave class early, am out of the room for an extended period of time, or sleep through class, I will not be given credit for the class.
_____I understand NO guns, knives, or any type of weapons will be allowed in the YWCA building. Any violation of this rule is grounds for immediate termination.
_____I understand cell phones must be turned off during group sessions. I will be asked to leave if it goes off during group sessions and will not get credit for the class.
______I agree I will not wear any offensive clothing in groupsessions. I will cover up any offensive tattoos.
______I understand if I have any questions or concerns, I can contact:
Janet Boudreau
DVIP Coordinator
Domestic Violence/Sexual Assault Services
810-238-1621 ext 309
CONT’IDENTIALITY
Confidentiality is Limited
A. Client agrees to have limited confidentiality while attending DVIP/ACE groups. Release öf ihformation will aIlo contact between the program and anyone listed on the release of information
B. Client recognizes and agrees that whatever is discussed in group sessions by other group members will remain confidential with other client identities.
I have read this contract and understand and agree with the requirements of the program
Participant Signature___________________________________Date____________________
Witness Signature ______________________________________Date____________________

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