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Domestic Violence

Informed Consent for Domestic Violence Treatment


I ______________________________________________ DOB:______________  Case No.________________________ request to be accepted for Domestic Violence, Assessment,  Education & Treatment.


  1. Name of Referring Court:  ____________________________________________________________________________
  2.  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:

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