CPS BIPP Intake Form

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 Behavioral Solutions of Texas, LLC-BIPP. This right applies with the following exceptions:

1. When a court of law subpoenas information shared by you with your counselor
2. 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. In accordance to the Code of Ethics of the Texas State Boards of Licensed Professional Counselors, Chapter 681, Subchapter C, Rule 681.43:A licensee shall report to the Texas Department of Protective and Regulatory Services (TDPRS) if required by any of the following laws:
   1. the Family Code, Chapter 261, concerning abuse or neglect of minors;
   2. the Human Resources Code, Chapter 48, concerning abuse, neglect or exploitation of elderly or disabled persons.
      Also, when staff determines that there is probability of imminent physical injury to self or others, staff will take safety initiatives and may if appropriate, notify medical or law enforcement personnel and/or the victim/partner (Section 611.004 (a) of the Texas Health and Safety Code).
3. When there is disclosure of sexual misconduct or sexual exploitation by a previous therapist or mental health professional. In accordance to the Code of Ethics of the Texas State Board of Licensed Professional Counselors, Chapter 681, Subchapter C, Rule 681.43:
   A licensee shall report if required by any of the following laws:
   1. the Health and Safety Code, Chapter 161, Subchapter K, Rule 161.131 et seq.,concerning abuse, neglect and illegal, unprofessional or unethical conduct in an inpatient mental health facility, a chemical dependency facility or a hospital providing comprehensive medical rehabilitation services; and
   2. the Civil Practice and remedies Code, 81.006, concerning sexual exploitation by a mental health service provider.
   3. All personal data and possibly additional information will be submitted to TDCJ-CJAD by the program or provider for the purposes of performing program assessments and other research.
   4. Media Involvement- Any media contact arranged by the Behavioral Solutions of Texas, LLC program or provider shall include the presence of an Behavioral Solutions of Texas, LLC employee to protect victim’s confidentiality.
4. In order to create a safe environment, all questions related to incidents of domestic Violence should be answered honestly by potent

I have read and understand the above statement and voluntarily enter into counseling services from the staff of Behavioral Solutions of Texas, LLC-BIPP.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Additional Charges or Arrests:

Family Status

Children

Please provide their information

How do you discipline your child/children?

Drug & Alcohol History

Counseling History

If, yes-Please provide a list of the medications to your primary counselor.

(Relationship Questions)

Victim Information

Victim Information (Answer "SELF" if you are the victim)

The victim that was involved in the offense-is that person your:

(I have no knowledge of the victims, address, e-mail, or phone number or any contact information, I hereby sign a sworn statement.)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Consent for Disclosure Information

• I understand that such disclosure will be made for the purposes of information exchange, progress reports, coordination of services, other investigative departments and referrals and facilitating victim safety. Disclosure is limited to information regarding attendance, participation, information exchange, coordination of services and referrals & facilitating victim safety.
• 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 completion of or termination from Behavioral Solutions of Texas, LLC-BIPP. I understand the right to confidentiality. I further understand that this consent form gives Behavioral Solutions of Texas, LLC-BIPP permission to share confidential information in the way described above.
• Release of information is voluntary, I understand I have a right to refuse Behavioral Solutions of Texas, LLC-BIPP request for this disclosure.Behavioral Solutions of Texas, LLC-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

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Consent for Disclosure of Information for Partners

• 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 Behavioral Solutions of Texas, LLC-Batterers Intervention & Prevention Program.
• I understand my right to confidentiality. I further understand that this consent form gives Behavioral Solutions of Texas, LLC-BIPP permission to share confidential information about me in the way described above. I understand that Victim will be contacted by the Victim Advocate an offered counseling services. She will be provided enrollment, completion or termination information from Behavioral Solutions of Texas, LLC-BIPP.
• Release of information is voluntary, I understand I have a right to refuse Behavioral Solutions of Texas, LLC-BIPP request for this disclosure.
• Behavioral Solutions of Texas, LLC-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.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Individualized Plan

Whether you are sanction to attend our group or here on a volunteer basis, each client must develop their own goals.

3) Client’s Personal Goal for attending BIPP:

(In the event that you are deemed inappropriate for battering intervention and prevention program services. Behavioral Solutions of Texas, LLC- Staff will make recommendations to the referral source for additional services or treatment. Clients with severe mental health problems such as:chronic depression, personality disorders, or suicidal or homicidal ideation), disruptive behavior, substance abuse problems, and/or generalized violence may not be appropriate for the program and should be referred back to the referral source.)

BATTERING INTERVENTION & PREVENTION PROGRAM

POLICY FOR CLIENTS & TERMINATION POLICY

I have received a copy of the “Policy for Clients” for Behavioral Solutions of Texas, LLC-BIPP. I understand my rights and responsibilities and I agree to enter Behavioral Solutions of Texas, LLC-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 Behavioral Solutions of Texas, LLC-BIPP to the client. I understand that the Behavioral Solutions of Texas, LLC-BIPP shall:

1. Provide services in a manner that I can understand. 2. Provide copies of all written agreements. 3. Notify me of changes in group time and schedules. 4. Comply with anti-discrimination laws. 5. Report quarterly to probation, courts of law, and/or other referral agencies regarding my progress or lack of progress during group. 6. Report to me regarding my status and participation. 7. Provide fair and humane treatment.

TERMINATION POLICY

As a client of Behavioral Solutions of Texas, LLC-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 Behavioral Solutions of Texas, LLC-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. Behavioral Solutions of Texas, LLC-BIPP also has the right to terminate services with clients if :

• A.Continued abuse, particularly physical violence. B. Client has accumulated (2) consecutive absences or a total of (5) sessions. C. Client has failed to pay for services over $100 dollars E. Client is believed to be violent/aggressive towards others or staff. F. Client is involved in illegal activities on the premises. G. Client need for treatment is incompatible with types of services H. Behavioral Solutions of Texas, LLC-BIPP Client violates any of the BIPP rules. I. Clients have the right to seek other resources outside of Behavioral Solutions of Texas, LLC-BIPP and when possible Behavioral Solutions of Texas, LLC-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.

Behavioral Solutions of Texas, LLC-BIPP will provide batterers at the time of assessment (intake) with a copy of the circumstances under which they can be terminated before completion.

The Behavioral Solutions of Texas, LLC-Batterers Intervention Prevention Program is an organization which provides services to a variety of individuals including victims of domestic violence, and perpetrators of domestic violence. Types of services include: Group Counseling, Community Education, Information & Referrals.

Staff Qualifications
The personnel providing the above services include counselors, administrative staff and interns, Counselors who have a bachelors or masters degree in counseling, psychology, criminal justice, social and work or a related field. Also, an intern completing his/her master’s degree may provide services. Counseling interns are supervised by our professional staff. Other services are provided by our staff, bachelor-level interns and trained volunteers.

Cancellation & No-Shows
Intake /orientation sessions and individual intake services are by appointment only. You are responsible for keeping your appointments and arriving on time. It is your responsibility to notify the office 24 hours in advance to reschedule with your counselor if you cannot keep an intake or individual appointment.

About Counseling
The staff believes that most clients have the ability to resolve their problems with a counselor’s assistance. An initial session is scheduled for the purpose of evaluation and to formulate a plan that is within the Battering Intervention & Prevention Project Guidelines for the State of Texas. While your counselor may offer tools for change, it is the client’s responsibility to use the tools. You have the right to refuse or to negotiate modifications of any technique that you believe is harmful. Possible positive or negative effects of entering or not entering counseling and/or not using certain techniques may be discussed at any time during our counseling relationship at the initiation of either you or your counselor. You are in complete control and you may end your service relationship at any time. Should you and/or your counselor believe that additional referrals are needed, appropriate referrals will be made. It is your responsibility to pursue referrals and recommend resources. Although intake/orientation sessions and group may be very personal, the relationship between you and your counselor is professional rather than social. Contact with your counselor will be limited to initial sessions and group. You will be best served if the individual sessions are by appointment. * In the event of an emergency you may contact 911, or visit your nearest emergency facility.

Policy for Clients
Records & Confidentiality

A summary of our communication becomes part of the clinical record, which is accessible to you on request. Confidentiality is defined as keeping private the information shared by you with your counselor. The Behavioral Solutions of Texas, LLC-Batterers Intervention Prevention Program personnel may access your records for data collections, case staffing, joint case management or clinical supervision. 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 Project guidelines:
Clients are required to sign a Consent for Release of Information, which permits information to be released to the victim/partner and or designated representative, law enforcement, the courts, correction agencies and any others in accordance with agency policy. A statement signed by you is required before any information may be released to anyone outside The Behavioral Solutions of Texas, LLC-Batterers Intervention Prevention Program. This right applies with the following exceptions:

(a) when a court of law subpoenas information shared by you with your counselor;
(b) when there is reasonable concern that harm may come to you or others (i.e., child abuse, suicide or homicide); and
(c) when there is disclosure of sexual misconduct or sexual exploitation by a previous therapist or mental health professional. Additionally, all instances of suspected or confirmed child abuse and/or neglect are required by law to be reported to Child Protective Services. You have the right to refuse the release of information to other individuals or agencies.

We ask that you keep confidential information you may learn about other clients who are receiving services from The Behavioral Solutions of Texas, LLC-Batterers Intervention Prevention Program.

Ethics & Grievances
All agency services will be delivered in as professional and ethical manner as possible. It is impossible to guarantee any specific results regarding your goals. However, if you have concerns regarding your counselor’s services, please inform your counselor. If your counselor is not able to resolve your concerns, you may report your complaint to your counselor’s immediate supervisor

If you have a complaint about professional performance of any of our staff please contact:
Texas Council on Family Violence at 800.525.1978

Behavioral Solutions of Texas, LLC BIPP Objective & Strategies

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:

1) 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 his 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.

TERMINATION POLICY

As a client of Behavioral Solutions of Texas, LLC-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 Behavioral Solutions of Texas, LLC-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. Behavioral Solutions of Texas, LLC-BIPP also has the right to terminate services with clients if :

A.Continued abuse, particularly physical violence. B. Client has accumulated (2) consecutive absences or a total of (5) sessions. C. Client has failed to pay for services over $100 dollars E. Client is believed to be violent/aggressive towards others or staff. F. Client is involved in illegal activities on the premises. G. Client need for treatment is incompatible with types of services H. Behavioral Solutions of Texas, LLC-BIPP Client violates any of the BIPP rules. I. Clients have the right to seek other resources outside of Behavioral Solutions of Texas, LLC-BIPP and when possible Behavioral Solutions of Texas, LLC-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. Behavioral Solutions of Texas, LLC-BIPP will provide batterers at the time of assessment (intake) with a copy of the circumstances under which they can be terminated before completion.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

CHILD PROTECTIVE SERVICES (CPS) - PURCHASED CLIENT SERVICES

Instructions: People have many different ways of relating to each other. The following statements are all different ways of relating to or thinking about your partner. Please read each statement and decide how much you agree with it.

CLIENT INFORMATION

How much do you agree with each of the following statements?

CLIENT ORIENTATION TO COUNSELING SERVICES

Purpose: Client acknowledgement of the information received from the Contractor describing the services offered, hours of operation, after-hours emergency contact, local community's behavioral health care crisis response information, and Client rights, programs rules, and privacy protections.

Contractor Directions: Complete this form and provide to the Client at the Client Orientation.

Services to be Provided

Provider Contact Information

Address: 8530 FM 1960 Rd E Ste 107
City, State, Zip: Humble, Texas 77346
Phone: (281)713-9004 | Email joe@behavioralsolutionsoftexas.com
Contact Person: Joseph Brown LCSW-S

Program Rules: Appointments and cancellations should be made through the office. Cancellations must be made 24 hours prior to the appointment. Late cancels may be counted as No Show. 3 No Shows may result in Unsuccessful discharge. It is client responsibility to contact this office to schedule all appointments after initial contact.

After-Hour Emergency Contact

Information Provided

I acknowledge that Joseph Brown, LCSW-S has provided me with an orientation of the services that I will be receiving and has provided me with all of the information indicated on this form.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

CPS ZOOM SESSION RULES AND ATTENDANCE POLICY

These guidelines are necessary to maintain the integrity of our On Line therapeutic sessions. Groups must function as though clients and therapists are in an office setting.

1. Client is responsible to be in clear and stable WIFI connection
   a. If no clear connection is available in office sessions are required.
2. Client must be stationary - no driving or riding in a vehicle and no walking/moving around.
3. Client must be in a private location with no one else in the room/car.
4. Client must be fully and appropriately clothed during the session.
5. Client Must have face consistently visible in the camera - no cameras can be obstructed a. Backgrounds may not obstruct a clear view of the clients face.
6. Clients may not be admitted to group after 5 minutes late, after 5 minutes late session will be counted as No Show. The session will not be counted.
7. 2 or more No Show or late Canceled sessions may result in unsuccessful discharge.
8. Clients will be responsible to reschedule sessions with the office 10:00 am to 2:00 pm Mon-Thu. Therapists may approve make up sessions during group only-- Email, text or phone calls with the therapist will not be considered as notification.
9. Failed Drug screens must be reported and an individual session scheduled-No exceptions. Relapse/drug or alcohol use should be reported during group.
10. No Smoking or Vaping during Group
11. Noncompliance with any of the above rules will be counted as No Show and the session will not be considered complete.

I have read and understand that I may be not receive credit for Zoom sessions if I am not able to comply with these policies.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

RELEASE and WAIVER

RELATING TO PROVIDING COUNSELING RECORDS AND COMMUNICATING PERSONAL HEALTH INFORMATION

in all capacities and in consideration of counseling and assessment services provided by JOSEPH BROWN LCSW-S, and any and all counselors and staff of Behavioral Solutions of Texas, LLC ( all collectively referred to as “Behavioral Solutions of Texas, LLC”), do hereby release them and hold them harmless from disclosing copies of and the content of my records, including my therapy and counseling records and assessments, as well as releasing them and holding them harmless for providing any oral or written communications relating to any information concerning my mental or emotional health, or substance abuse history or status.

Included in this release is my voluntary approval for the release by Behavioral Solutions of Texas, LLC of my personal health information described above, including to individuals or entities associated with state or federal agencies, such as the Department of State Health Services or Health and Human Services Commission or the Texas Department of Family and Protective Services. I understand that such information eligible to be disclosed encompasses all of my personal health information, including my substance abuse history, substance abuse issues, substance abuse-related information from the current CPS case, and results of drug tests.

I understand that a part of my care at Behavioral Solutions of Texas, LLC involves screening and assessment of my substance abuse status and what type of substance abuse services I may need. I specifically authorize Behavioral Solutions of Texas, LLC to disclose all of my personal health information as is needed to convey my history and current status, such disclosure being potentially made to Texas Department of Family and Protective Services, and those associated with them including attorneys, Department of State Health Services or Health and Human Services Commission, and to law enforcement, attorneys, and courts with jurisdiction over any matter where my personal health information would be relevant to their proceedings. I understand that there may be other individuals and entities to which the disclosure of my records and personal health information needs to occur, and I authorize Behavioral Solutions of Texas, LLC to make such disclosures as they deem necessary.

These individuals and entities are released of, from and against any and all demands, actions, liabilities, obligations, judgments, executions, causes of action or other claims (collectively called “claims”) in connection with any injuries or damages to myself allegedly caused by the alleged acts, omissions or other fault of the individuals and entity hereby released. This Agreement includes, but is not limited to, all matters relating to care and treatment provided at any time to me by Behavioral Solutions of Texas, LLC, JOSEPH BROWN LCSW-S and or his offices.

I am legally and mentally competent to execute this release agreement and have voluntarily done so.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.