Intake Packet

Why This Form Is Important

This form collects essential information we need to:

Evaluate your situation.
Provide tailored support.
Ensure you meet program requirements.

Key Instructions

Honesty is Essential: be truthful and accurate when answering every question. Providing false or incomplete information can delay or even prevent your enrollment in the program.
Complete All Required Fields: most fields are marked as required and must be filled out. You will not be able to submit the form, move forward, or begin the BIPP program until the form is fully completed.
Review Before Submitting: double-check your answers to ensure they are correct. Once submitted, changes may not be possible without contacting our team.

Sections of the Form

The form includes the following sections:

Personal Information

Full Legal Name · Date of Birth · Contact Information (Phone, Email, Address)
Emergency Contact Details

Legal Information

Case Number (if applicable)
Court Details (if referred by court)
Probation Officer Information (if applicable)

Program-Related Information

Referral Source
Reasons for Enrollment
History of Participation in Similar Programs

Tips for Filling Out the Form

Take Your Time: ensure all information is accurate. The form is designed to save your progress in case you need to return later (if applicable).
Use Clear Language: avoid abbreviations or vague descriptions.
Double-Check Required Fields: look for any fields marked with an asterisk (*) and make sure they are complete.

What Happens After Submission?

Our team will review your responses to confirm form completion.
The form will be added to your BIPP chart.

If you have questions while filling out the form or encounter any technical difficulties, please contact our support team at: [contact number].

Note: Incomplete or inaccurate forms will not be accepted. Thank you for your cooperation!

Choose Your Program

Select your program to load the correct intake pages.

First Name First Name

Last Name Last Name

Email Email

Consent to Disclose

Lastly, lets get the legal stuff out of the way.

I authorize Lakeview Education to disclose to CSCD, caseworkers and/or Attorney(s) the results of the Education Program including: Recommendations, Test Scores, Successful Completion/Unsuccessful Discharge, or any other pertinent information related to the Education Program. I understand that all Education Programs shall abide by and obtain any consent to the disclosure required by applicable Federal and State Laws regarding confidentiality of patient/client records including, as applicable and without limitation, 42 U.S. Code § 290dd–2. Confidentiality of records, and Health and Safety Code, Chapter 611. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in response to it, and that in any event, this consent expires 60 days after completion of the Education Program in which I am enrolled has been completed.

I Agree

Today’s Date Today’s Date

Phone Number Cell Phone

Driver’s License Driver’s License Number

Gender Gender

Date of Birth Date of Birth

County of Arrest County of Arrest

Charge Reason Charge or Reason for Arrest

PO / Attorney / Caseworker PO, Attorney, or Caseworker Name

Location PO / Attorney / Caseworker County or Location

Offense Level Offense Level

Rules and Regulations

Rules and Regulations:

Respect the privacy of others. Be respectful to others in the class.
Be on time. Do not attend the class under the influence of alcohol or other substance.
Keep up with your payments.
Stay off your cell phone. (In class)
Participate and share with others (you might be helping someone)

I read and agree to the Rules and Regulations

Email Email

Gender Gender

First Name First Name

Last Name Last Name

Today’s Date Today’s Date

Phone Number Phone Number

Date of Birth Date of Birth

PO / Attorney / Caseworker PO, Attorney, or Caseworker Name

Confidentiality Notice

Confidentiality: The following information will be kept confidential as per state and federal guidelines.

You acknowledge that program staff will protect your information in accordance with applicable laws and policies.

I have read and understand the confidentiality notice.

Drug Test History Have you ever failed a drug test?

Substance Treatment History Have you ever received treatment for substance addiction(s)?

Drug of Choice Drug of Choice (if any)

Current Charge / Situation Current arrest/charge/investigation or situation.

Consent to Share Attendance Only

I understand and give my consent to share only information concerning my participation and attendance in the program with the referral source provided. I understand that I can withdraw this approval at any time.

I agree

Today's Date

First Name

Last Name

Phone Number

Driver License Number

Street Address

City

State

ZIP

Gender

Date of Birth

Race / Ethnicity

Marital Status

How many times have you been married?

Did drinking/drugging contribute to marital/family problems?

Yes No Maybe N/A

Education Level

Jobs held in last 3 years Job — Year(s) — Reason for leaving

Total time unemployed in last 3 years

Case / Cause #

County of Arrest

Probation / Attorney Name

Probation / Attorney County

How many times have you been arrested?

Year(s) of arrest(s)

Were you charged with DWI?

Yes No

Blood Alcohol Concentration (BAC)

License status (current)

License status at time of arrest

Was there an accident involved?

Yes No

Was anyone injured?

Yes No N/A

Send completion certificate to DPS (Austin)?

Yes No

Confidentiality Notice

*** The Following Information Will Be Kept Confidential ***

You acknowledge that program staff will protect your information in accordance with applicable laws.

I have read and understand the confidentiality notice.

Where do/did you usually use drugs or alcohol?

Party/Social Event Night Club/Bar Home with Family/Friends Home Alone

On the Street Work/School Restaurant

Other

Age when you began drinking/using

Age of first arrest

Age of first drug-related arrest

Ever thought you might have an alcohol or drug problem?

Yes No

If so, have you ever received help?

Yes No

Have you ever attended any of the following?

AA or NA Drug/Alcohol Rehab Relative Church

Psychiatrist/Psychologist Substance Abuse Counselor Doctor

Other

Consent: Disclose Results I authorize Lakeview Education to disclose to CSCD and/or Attorney(s) the results of the Education Program including: Recommendations, Test Scores, Successful Completion/Unsuccessful Discharge, or any other pertinent information related to the Education Program. This question is required.

Consent: Confidentiality Laws I understand that all Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State Laws including 42 U.S. Code § 290dd–2 and Health and Safety Code, Chapter 611. I may revoke this consent in writing except to the extent action has been taken in response; this consent expires 60 days after program completion. This question is required.

Consent: Share With Court I understand and agree that information about my progress in the DWI Education Program will be shared with the Court and do hereby authorize such use. This information will otherwise be held confidential and not released without my signed consent. This question is required.

First Name

Last Name

Disclosure Consent I authorize Lakeview Education to disclose to CSCD and/or Attorney(s) the results of the Education Program including: Recommendations, Test Scores, Successful Completion/Unsuccessful Discharge, or any other pertinent information related to the Education Program. This question is required.

Confidentiality Laws Acknowledgment I understand that all Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State Laws including, as applicable and without limitation, 42 U.S. Code § 290dd–2 and Health and Safety Code, Chapter 611. I may revoke this consent in writing except to the extent action has been taken, and in any event this consent expires 60 days after completion of the Education Program. This question is required.

Driver License Number

Street Address

Phone

Gender

Date of Birth

Race / Ethnicity

Marital Status

How many times have you been married? (if any)

Did drinking/drugging contribute to marital/family problems?

Yes No Maybe N/A

Education Level

Job History (last 3 years) List all jobs you have held in the past 3 years, beginning with your present job. Include: Job Description, Year(s) of Employment, Reason for Leaving.

Total time unemployed in last 3 years

Case / Cause Number

County of Arrest

Probation / Attorney Name

Probation / Attorney County

Times Arrested (any reason)

Years of Arrest(s)

If charged with DWI, what was the BAC?

License status at time of arrest

Was there an accident involved?

Yes No

Was anyone injured?

Yes No

Send completion certificate to DPS (Austin)?

Yes No

Where do/did you usually use alcohol? (check all that apply)

Party/Social Event Night Club/Bar Home with Family/Friends Home Alone

On the Street Work/School Restaurant

Other

Age when you began drinking

Age of first arrest

Age of first alcohol-related arrest

Have you ever thought you might have an alcohol problem?

Yes No

If so, have you ever received help?

Yes No

Have you ever attended any of the following?

AA or NA Drug/Alcohol Rehab Relative Church

Psychiatrist/Psychologist Substance Abuse Counselor Doctor

Other

Court Sharing Consent I understand and agree that information about my progress in the DWI Intervention Program will be shared with the Court and do hereby authorize such use, with the further understanding that this information will otherwise be held confidential and not released to other individuals without my signed consent. This question is required.

Texas DWI Intervention — Participant Agreement As a participant in this program, you must follow these agreements and program requirements: • Participate in group discussions, 1-to-1 sessions, and homework • Express opinions without disrupting class • Bring a significant other to Modules 9 and 10 (Family Week) • Develop an action plan • Be on time; ≥15 minutes late or no-show may result in drop or added sessions • Return from breaks on time • No visitors except Family Week • Abstain from mood-altering chemicals • Attend at least two A.A. meetings between Modules 11 and 12 • For unavoidable absences, call to schedule a make-up before the next class; no more than two absences.

Agreement to Comply I agree to comply with all requirements, complete assignments and projects, and fully participate in class discussions.

Disclosure Consent I authorize Lakeview Education to disclose to CSCD and/or Attorney(s) the results of the Education Program including Recommendations, Test Scores, Successful Completion/Unsuccessful Discharge, or any other pertinent information related to the Education Program.

Confidentiality Laws Acknowledgment I understand applicable Federal and State confidentiality laws, including 42 U.S.C. §290dd-2 and Texas Health and Safety Code Chapter 611. I may revoke consent in writing except where action has already been taken. This consent expires 60 days after program completion.

First Name

Last Name

Date of Birth

Driver License Number

Street Address

Phone Number

Gender

Case / Cause Number

County of Arrest

PO or Attorney Name

PO or Attorney County

Send completion to DPS (Austin) for driver’s license?

Yes No

Marital Status

How many times have you been married?

Did drinking/drugging contribute to marital/family problems?

How many people reside in your home?

Education Level

Employment Status

Job History (last 3 years) List all jobs for the last 3 years: Job Description — Year(s) — Reason for Leaving.

Total time unemployed in last 3 years

Times arrested (any reason)

Times arrested for DWI / DUI

Blood Alcohol Concentration (BAC)

If BAC unknown, was it greater than 0.15?

Yes No Unknown

License conditions (including now)

Suspended Revoked Business/Work Only None of the above

License status at time of arrest

Was there an accident involved?

Yes No

Was anyone injured?

Yes No

Where do/did you usually use alcohol? (check all that apply)

Party/Social Event Night Club/Bar Home with Family/Friends Home Alone

On the Street Work/School Restaurant

Other

Age you began drinking

Age of your first arrest (any reason)

Age of your first alcohol-related arrest

Have you ever thought you might have an alcohol problem?

Yes No

Have you ever thought you might have a drug problem?

Yes No

If so, have you ever received help?

Yes No

Have you ever attended any of the following for help?

AA or NA Drug/Alcohol Rehab Relative Church

Psychiatrist/Psychologist Substance Abuse Counselor Doctor

Other

Court Sharing Consent I understand and agree that information about my progress in the Drug Offender Education Program will be shared with the Court and do hereby authorize such use, with the further understanding that this information will otherwise be held confidential and not released to other individuals without my signed consent.

1 Contact Information

Program

First Name

Last Name

Cell Phone

Date of Birth

Gender

Driver’s License Number

Street Address

City

State

Zip

City of Birth

Race

Highest Education

Currently Employed?

Confidentiality is defined as keeping private the information shared by you, the client, with your counselor. On occasion, other employees may need access to your record for agency teaching, supervision, and administrative purposes. These staff members will also respect the privacy of your records. In accordance with the Texas Department of Criminal Justice – Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention & Prevention Program guidelines, clients are required to sign Consent for Release of Information, which permits information to be released to the victim/partner and/or her designated representative, law enforcement, the courts, correction agencies, and any others in accordance with agency policy.

As a client, you have the right to withhold or release information to other individuals or agencies. A statement signed by you is required before any information may be released to anyone outside Lakeview Education – BIPP. This right applies with the following exceptions:

When a court of law subpoenas information shared by you with your counselor.
When there is reasonable concern that harm may come to you or others, as in child abuse, elder abuse, and abuse of a disabled person. Staff will notify appropriate agencies, including TDPRS (Texas Department of Protective and Regulatory Services), in accordance with applicable laws.
When staff determines there is a probability of imminent physical injury to self or others. Staff may notify medical or law-enforcement personnel and/or the victim/partner (Section 611.004(a) of the Texas Health and Safety Code).
When there is disclosure of sexual misconduct or sexual exploitation by a previous therapist or mental-health professional.

A licensee shall report if required by any of the following laws:

Health and Safety Code, Chapter 161, Subchapter K, concerning abuse, neglect, or illegal, unprofessional, or unethical conduct in facilities providing mental-health services.
Civil Practice and Remedies Code, §81.006, concerning sexual exploitation by a mental-health service provider.
All personal data and possibly additional information will be submitted to TDCJ-CJAD for program assessments and research.
Media involvement: Any media contact arranged by the Lakeview Education program will include the presence of a Lakeview Education employee to protect victim confidentiality.

We ask that you keep confidential information you may learn about other clients who are receiving services from Lakeview Education – BIPP.

Lakeview Education requires facilitators and participants to:

Disable any devices that could collect information from the environment, such as Google Home Assistant, Amazon Alexa, or Apple Siri.
Not record or take screenshots of group discussions.
Ensure they are in a private space and not in any public area such as a park, yard, or open area. Other people not in the group should not hear or observe the group.
Not use the virtual group session to expel their partner or children from the residence. Participants must relocate to another location or private room in the residence.
Ensure that children are safe and cared for, but not interrupting the session or listening to group discussions.

Observers may occasionally sit in on a group. Observers must sign a confidentiality statement. Observers may include student interns, trainees, other professionals, or community members. This facility is video-recorded for security purposes, and treatment sessions may be video/audio recorded for quality assurance.

Ethics & Grievances: All agency services will be delivered in as professional and ethical a manner as possible. While specific results cannot be guaranteed, if you have concerns about the professional performance of your counselor:

Inform your counselor directly.
If unresolved, report concerns to your counselor's immediate supervisor, Executive Director [contact name], at [contact number].
If further resolution is needed, contact the Texas Council on Family Violence at 800-525-1978.

By clicking “I Agree” below, I confirm that I have read, understood, and agree to abide by the terms and conditions outlined above. I acknowledge my rights and responsibilities as described, and I accept these terms as a condition of participation in the Lakeview Education – Batterers Intervention & Prevention Program.

I Agree – I have read, understood and accept the terms above

Name

Phone

Relationship

2b Military Service

Branch

Date of Service

Referral Type

Officer / Case Manager Name

Officer E-mail

Additional Charge or Arrest Dates (if applicable)

Additional Charge Details

4 Marital & Family Information

Living Situation *

Marital Status *

Do you have any children? *

Describe how you discipline your children. Please provide examples: (if applicable)

5 Substance Use History

Use of alcohol in the past? *

Use of alcohol currently? *

Use of drugs in the past? *

Use of drugs currently? *

Were you using alcohol when you were abusive? *

Were you using drugs when you were abusive? *

6 Counseling History & Mental‑Health Background

Have you ever been in counseling? *

Are you currently depressed? *

Have you ever attempted suicide? *

Are you taking any medications for a mental‑health condition? *

History of sexual abuse? *

Do you have any history of head trauma, brain injury, stroke, including overdose blackouts? *

History of weapon possession? *

History of abuse / trauma as a child? *

Describe the most recent violent incident / offense / etc:

7 Victim Information

Please select one:

I do not have knowledge of the victim's contact information

I do have knowledge of the victim's contact information (must provide below)

8 Client Consents

Consent for Disclosure of Information

I understand that such disclosure will be made for the purposes of progress reports, referrals, and facilitating victim safety.

Disclosure is limited to information regarding attendance, participation, information exchange, and referrals for services.

I understand that I may revoke this consent at any time and that my request for revocation must be in writing. If not earlier revoked, this consent for disclosure of information shall expire 1 year after my completion of or termination from Lakeview Education - Batterers Intervention & Prevention Program.

I understand my right to confidentiality. I further understand that this consent form gives Lakeview Education - BIPP permission to share confidential information about me in the way described above.

I understand that Victim will be contacted by the Victim Advocate and offered counseling services. She/He will be provided enrollment, completion, or termination information from Lakeview Education - BIPP.

Release of information is voluntary; I understand I have a right to refuse Lakeview Education - BIPP's request for this disclosure.

Lakeview Education - BIPP reserves the right to dismiss any client who refuses to meet the provisions of The Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention & Prevention Project guidelines.

Information disclosed by batterers during an assessment (intake), group sessions, and exit is confidential and shall not be shared with victims.

By checking "I Agree", I confirm that I have read, understood, and agree to abide by the terms and conditions outlined above. I acknowledge my rights and responsibilities as described, and I accept these terms as a condition of participation in the Lakeview Education - Batterers Intervention & Prevention Program.

Lakeview Education Program Agreement

Fee per session is: Parole Intake Orientation $20, $15.00 per group ($310 total), $20 Completion; Probation 18 Week – Intake Orientation $30, $30 per group, $30 Completion ($600 total); Probation 27 Week – Intake Orientation $30, $20 per group, $30 Completion ($600 total). This fee is only one type of demonstration of your accountability and restitution for violent behavior. Breaks, Assessment (intake), Orientation, or Exit Session are not to be included towards the 36 hours (18 weeks) or 54 hours (27 weeks).

Battering Intervention and Prevention Program consists of Assessment (Intake) and Orientation and at least 36 hours of group sessions in a minimum of 24 weekly sessions. Not to exceed one session per week. If dismissed, the client must apply to re-enter into Lakeview Education BIPP. Re-entry is considered on a case-by-case basis. I understand that I cannot re-enter the program until I have paid off my previous balance.

Clients who miss (3) consecutive sessions (group or individual) or a total of (5 sessions), you will be discharged from the program. Your referral sources will determine what happens with your case as a result of your absences. There are no excused absences. Incarceration is an inexcusable absence. Clients have the option to attend “Attendance Review” if the client is facing discharge.

You must be focused and facing your webcam during the entire group; NO watching TV or working on your computer. You will only be given one warning. Second warning will result in no credit for the session and/or a discharge violation from Lakeview Education BIPP program.

You must be in a quiet room; not driving, in your car, or doing any other activity. Otherwise, you will receive no credit for that BIPP session and/or receive a discharge violation from Lakeview Education BIPP Program.

If there is any interruption during your Lakeview Education Group by a child or adult, you will lose credit for your class and/or receive a discharge violation from Lakeview Education Program.

If there is any appearance of alcohol or vaping during Lakeview Education Group, it will result in a request for a drug test. If found dirty, you must sign a behavioral contract or be unsuccessfully discharged from Lakeview Education BIPP Program.

During your Lakeview Education, if there is any woman present even for a moment, especially the victim, you shall receive no credit for the class and/or be unsuccessfully discharged from Lakeview Education BIPP Program.

If after a restroom break you do not return, or you take more than 5 minutes, you shall receive no credit for your Lakeview Education BIPP Group session.

Payment for services is due at the time service is rendered. You will not be credited for attending groups or individual sessions unless payment is received. The client is required to maintain no more than a $30 balance. I will continue to attend until I have a zero balance. Attendance may exceed 24 weeks if payment is not completed.

I hereby agree to arrive to all of my sessions on time. If you are 5 minutes late after the designated start time, you will not receive credit for attending group.

I understand that I must register into the group upon online login with the group facilitator. I will not be counted present for the session unless I register in with the group facilitator.

I will notify Lakeview Education BIPP of any change of address or phone number.

I hereby agree to contact BIPP by phone at [contact number] when I am unable to attend a scheduled session. Failure to contact Lakeview Education within 2 consecutive absences is an automatic discharge from Lakeview Education Program.

I agree not to attend group under the influence of alcohol or drugs; refusal of a Drug Screening is an automatic discharge. It will be my responsibility to arrange transportation home or any safety measures so I'm not a danger to myself or others for driving under the influence. The referring agency will be notified of the incident.

I hereby agree not to be abusive towards any staff person or other group member. I understand that I may not use sexist or racist language.

I hereby agree to respect the confidentiality rights of my fellow client/group members. I further understand that a violation of this rule shall result in immediate termination from the program and shall be reported to the proper authorities.

I hereby agree to notify a staff person of any and all emergencies that I am either part of or witness to.

I understand that Lakeview Education BIPP is committed to helping me gain a better understanding of my problems and how to find productive solutions and that it is the main goal of my psychoeducational classes.

Taking Responsibility

During group discussions, participants may not blame anyone else for their own behaviors.

Participants agree to not use any form of violence, abusive, threatening, and controlling behaviors including stalking during the weeks they are in the program. A participant who uses violence may be terminated from the program. This action will be reported to the participant’s referral agencies. Participants will cease violent, abusive, threatening, and controlling behaviors, including stalking and violation of a protective order. Participants who are terminated for this reason and wish to re-enter the program will re-start from the 1st week.

Participants will develop and adhere to a non-violence plan as outlined in the program curriculum.

Lakeview Education requires me to disable any devices that could collect information from the environment, such as Google Home Assistant, Amazon Alexa, or Apple Siri, and I agree that I will not record nor take screenshots of the group. Lakeview Education requires me to be in a private space and not in any public area such as a park, yard, or open area; other people not in the group should not be exposed to the content nor hear or observe the group.

This includes changing locations, walking around the house, neighborhood, or any public space. The responsibility of having a private area is mine. I cannot use the virtual group session to expel my partner or children from the residence. I must relocate to another location or private room in the residence. If I am a parent, I agree to ensure my children are safe and taken care of but are not interrupting the session or listening to group discussions.

BIPP Client Policy & Termination Policy

I have received a copy of the "Policy for Clients" for Lakeview Education - BIPP. I understand my rights and responsibilities, and I agree to enter Lakeview Education - BIPP.

I understand that in accordance with Guideline 31 of the Texas Department of Criminal Justice-Community Justice Assistance Division and Texas Council on Family Violence Battering Intervention Prevention Program guidelines, I am being provided a written agreement that clearly delineates the obligation of the Lakeview Education - BIPP to the client. I understand that the Lakeview Education - BIPP shall:

Provide services in a manner that I can understand.
Provide copies of all written agreements.
Notify me of changes in group time and schedules.
Comply with anti-discrimination laws.
Report quarterly to probation, courts of law, and/or other referral agencies regarding my progress or lack of progress during group.
Provide reports weekly and/or monthly about my BIPP progress to my referral source: Probation, Parole, Child Protective Services, Courts, Attorney.
Report to me regarding my status and participation.
Provide fair and humane treatment.

As a client of Lakeview Education - BIPP, you have the right to terminate services with our agency at any moment. The risk of terminating services will be explained to you by a counselor/instructor. You have the right to choose other agencies for your services, and Lakeview Education - BIPP will provide you with a list of known community agencies that may provide the services you need, except for clients referred by Probation; clients will be referred back to their Supervision Officer.

Lakeview Education - BIPP also has the right to terminate services with clients if:

Continued abuse, particularly physical violence.
Client has accumulated (3) consecutive absences or a total of (5) sessions.
Client has failed to pay for services over $30.
Client is believed to be violent/aggressive towards others or staff.
Client is involved in illegal activities on the premises.
Client need for treatment is incompatible with types of services.
Lakeview Education - BIPP client violates any of the BIPP rules.

A report will be made within 5 working days to your referral source of any known law violations, incidents or physical violence, and/or termination from BIPP.

Clients have the right to seek other resources outside of Lakeview Education - BIPP, and when possible, Lakeview Education - BIPP staff will provide or make a referral.

The above Termination Policy applies to clients who are attending services on a voluntary basis or court-ordered to receive services or who are mandated to receive services by other entities; however, clients are responsible to check with those entities who mandate them to come regarding the alternatives for receiving services in another agency or consequences for choosing to stop services before making this final decision.

Lakeview Education - BIPP will provide batterers at the time of assessment (intake) with a copy of the circumstances under which they can be terminated before completion.

I have read and understand the above statements and voluntarily enter into counseling services from the staff of Lakeview Education - BIPP - by entering my name below. (By clicking SUBMIT, I hereby confirm the above information to the best of my knowledge is correct and true, with no misleading or false content in accordance with Texas Perjury Statute, Sec. 37.02 (a) (2) Chapter 32, Civil Practice and Remedies Code.)

9A. Individualized Plan

Choose your reason(s) for attending the Battering Intervention & Prevention Program (BIPP): *

Protective Order

Aggravated Assault

Violation of Protective Order

Choking / Strangulation Charge

Interfering with a 911 Call

Terroristic Threat

Injury to a Child

Other

Describe the reason you are here (offense) *

Your personal goal for attending BIPP *

EXAMPLE: Objective: Client will increase his knowledge regarding the issue of abuse, domestic violence and skills that can help him change behaviors and eliminate abuse and violence from his relationships. Strategies: Client will attend the BIPP group weekly for 90 minutes and will participate actively and display receptiveness to the information presented. Client will make consistent application of skills presented by thinking about the new information presented, reviewing the handouts, talking about what he’s learning with others, asking questions, making application of skills, completing assigned homework, giving examples in group of the progress he is making and by only focusing on him and his relationship with his partner. Client will practice POSITIVE SELF-TALK by stating I DON’T ARGUE, I DON’T FIGHT AND IF NEEDED I TAKE A TIME-OUT SO THAT I KEEP ME AND MY FAMILY MEMBERS SAFE FROM ABUSE AND VIOLENCE.

9B. Case Notes

Counselor

Start Date & Group Selection

Chosen Group Time *

Upcoming Group Dates

Chosen Start Date * Select the date you want to start. If you picked a date above, it will fill automatically.

Required Evaluations

Complete all intake evaluations below before submitting intake. Each evaluation opens in a new tab.

After completing one, return here and click Refresh Status.

Evaluation status will appear after you select your program.

10 Digital Signature

Entering your name constitutes a digital signature. By clicking SUBMIT, I hereby confirm the above information to the best of my knowledge is correct and true, with no misleading or false content in accordance with Texas Perjury Statute, Sec. 37.02 (a) (2) Chapter 32, Civil Practice and Remedies Code.

Signature – type your full legal name

Date Signed

Signature and Submit

Full legal name

Date

Draw signature

I certify the information provided is true and correct.