Informed Consent for Domestic Violence Treatment
I ______________________________________________ DOB:______________ Case No.________________________ request to be accepted for Domestic Violence, Assessment, Education & Treatment.
- Name of Referring Court: ____________________________________________________________________________
- Address of the Referring Court:_______________________________________________________________________
I have been informed of the following policies about the Domestic Violence:
The Domestic Violence treatment shall be completed in not less than three months and no more tan 12 months after the start of treatment.
Domestic Violence Timeframe:
___ First Offense: 26 sessions
___ Second Offense: 36 sessions
___ Third Offense 52 sessions
Type of Counseling sessions: Individual and/or Group
Timeframe of sessions: ___ Individual session minimal 50 minutes
___ Group session minimal 90 to 180 minutes
Costs of Sessions: ___ Initial Evaluation $180.00
___ $50.00 per each Individual session
___ $35.00 per each Group session
Court will be notified of completion date and/or non-compliance status.
Client Signature: Date:
Staff/Clinician Signature: Date:
Please download, complete and bring this form to your appointment: