w/ SA Assessment included

                                                                                                        VICTIM

Family Focus Counseling Services, PC is a certified Batterer Intervention Program in the State of Virginia. We are commited to victim safety and offender accountability.

                                                                                  FAMILY FOCUS COUNSELING SERVICES, PC

                                                                                            NOTIFICATION OF CLIENT RIGHT

As a client of Family Focus Counseling Services, you are assured of the following Rights:

• Impartial access to services regardless of race, religion, sex, ethnic background or handicap.
•  Participation in the development and completion of your treatment plan.
• Written information on program policies and procedures, fee schedules, and reimbursement of policies and rules of conduct.
• Confidential maintenance of all information regarding you and the services you receive within the confines of the law.
• The options to inspect, copy, or correct the above written information, at your expense.
• To be treated with dignity and respect at all times.
• The human, civil and legal rights granted to all citizens.
• In addition, at no time will rights granted to you by the law be restricted without due process.
• Nor will you be denied any rights, privileges, or benefits solely the results of being a recipient of services.
• If you need assistance in understanding any of the rights, you or your authorized representative is encouraged to seek help from any staff member.

If you feel that any of these Rights are being violated or infringed, you are encouraged to bring your concern to the attention of any staff member with whom you work, the Supervisor or Director of the program you attend, or any other employee of Family Focus Counseling Services. Complaints brought to our attention will be addressed in a timely manner and resolved as quickly as possible. If unresolved to your satisfaction, an appeal may be made directly to the Local Human Rights Committee. Full details of the complaint procedures may be obtained from any staff member.

If you need further assistance, the Virginia Department of Behavioral Health & Developmental Services provides an Advocate for you. This person will assist you in further understanding of your rights and, if necessary, will assist in an inquiry as to your concern. You may contact this person at:

                                                                                                   Office of Human Rights

                                                                                                            Region 1&2                                                                                  
                                                                                                    Cassie Purtlebaugh

                                                                                                          (804) 382-3889  

I have received a copy of this notification of my rights and have been offered assistance in understanding them.

Family Focus Counseling Services, PC is a certified Batterer Intervention Program in the State of Virginia. We are commited to victim safety and offender accountability.

here by authorize Family Focus Counseling Services, P.C. to release or receive information that concerns my involvement with the program here or background information useful to my treatment.

This consent and authorization allows Family Focus Counseling Services to obtain such information as it relates to my emotional, mental, or physical health: medical records, school records, court records and current legal charges. I allow Family Focus Counseling Services to receive confidential information on my history of drug/alcohol use while in treatment. I understand these records are protected under Federal and State confidentially laws and cannot be disclosed without my written consent.

This consent authorizes Family Focus Counseling Services to contact the victim when I begin the program, if I am terminated from the program, and when I have completed the program. The victim may also be notified when deemed necessary in the treatment process or when perceived in physical danger. Any Victim’s Witness or Domestic Violence personnel may be contacted both to release and receive information when necessary.

This consent authorizes Family Focus Counseling Services to contact and receive information from Court Service workers and/or Probation officers concerning background information and current legal charges, any results from testing or assessments, attendance, and participation in the program.

By affixing my signature, I attest that I have read or have been read this document and fully understand it. I consent and request that all persons or agencies accept a photocopy of this authorization as valid authorization to give such information

this program is confidential. I hereby promise not to discuss any client identification or details of counseling sessions with anyone other than properly authorized program staff. I understand that to violate this promise can lead to criminal and civil penalties as well as program dismissal.

Program staff has the duty to warn third parties about the potential for violence or other serious harm directed against them. Virginia Code 54.1-2400.1 outlines the scope of this duty, actions which discharge this duty, and applicable civil liability protections for proper discharge of this duty. If the intake evaluation or subsequent contact reveals suspected incident of child, elder, or disabled adult abuse or neglect, program staff must report this to Child Protective Services or Adult Protective Services, respectively.

Family Focus Counseling Services, PC is a certified Batterer Intervention Program in the State of Virginia. We are commited to victim safety and offender accountability

                                                                                      FAMILY FOCUS COUNSLEING SERVICES

                                                                                           FEE DETERMINATION AGREEMENT

                                                            TREATMENT AND DATA COLLECTION AUTHORIZATIONAUTHORIZATION

√  Authorized Treatment/Training by Family Focus Staff

√  Payment in full at the time of each session

√ Authorized collection of administrative information and clinical records which will be kept confidential and will not be released without written consent, except when:

1. A Bona Fide Medical or Psychiatric Emergency necessitates release of information.

2. Suspicion of Child Abuse or Neglect must be reported.

3. Reviewed by Quality Assurance reviewers from Regulatory Agencies.

4. Properly ordered by a court of competent jurisdiction.

√ Authorized immediate emergency intervention and/or emergency referral in case of physical crisis or injury.

√ I understand that I am financially responsible to Family Focus for all charges.

√ I have been advised that I will be financially responsible for missed appointments at full fee.

√ I certify that I understand all of the above Authorizations and give my permission for verification of all or any part of the information contained herein.

                                                                       BREATHALYZER POLICY AND PROCEDURES

• Drinking alcoholic beverages or use of any illegal substance while attending any program at our facility is a violation of our program policy and is grounds for termination from the program. Our goal is for you to be substance free during the length of your group counseling or individual program at our facility.
• Drinking before attending group sessions is a violation of our facility policy.
• Insuring compliance with this requirement protects you and the integrity of your counseling group. Therefore, every participant must submit to random alcohol detection breathalyzer test prior to counseling sessions, be it in group or individual sessions.
• Anyone testing positive for the presence of alcohol, or refusing to take the breathalyzer test, will not be allowed to participate in that session, and his/her probation officer must be notified.
•  Additionally, anyone with a positive breathalyzer test will be allowed to use the telephone and wait at Family Focus to make alternative transportation arrangements if he/she arrived driving a vehicle. The police will be notified immediately of anyone electing to drive from Family Focus under the influence of alcohol.
• By my signature on this document I affirm that I have read, understand, and agree to comply with this policy

Family Focus Counseling Services, PC is a certified Batterer Intervention Program in the State of Virginia. We are commited to victim safety and offender accountability.

                                                                                    FAMILY FOCUS PROGRAM OBLIGATION

Family Focus is committed to the goal of stopping: coercive, dominating, violent, and abusive behavior; and the safety of the victims and their children.

To reach this goal Family Focus agrees to:

Provide services appropriate to participants needs.

• Provide a copy of all written agreements when requested.
• Notify the participants of changes in group times and schedules.
• Report to the court, local community corrections program, other appropriate authority regarding participant’s progress and compliance with court orders and program rules.
• Report to the appropriate person(s) including the victim, courts local community corrections, or other justice system agency of any bodily harm or threats of bodily harm to the victims or any other person, any threats or attempts to commit suicide, or any belief that child abuse or neglect has occurred.
• Report regularly to the participant regarding his progress.
• Provide fair and humane treatment.

Family Focus Counseling Services, PC is a certified Batterer Intervention Program in the State of Virginia. We are commited to victim safety and offender accountability.

                                                                                INFORMATION RELEASE/REQUEST FORM

Regarding

Family Focus

170 West Shirley Ave., #206

Warrenton, Virginia 20186   (540) 349-4537    FAX: (703) 543-1269

I consent to the release of information described above. I may revoke my consent at any time by delivery of a written notice to the source of information specified above. It will be effective upon the date the notice is received by them, but excluding information already furnished by them before that date. In the absence of my formal written notice, this consent is revoked automatically on the date indicated below.

To the recipient of this information:

His/her information is being disclosed to you from records whose confidentiality is protected by Federal law. Federal regulations (42 CRF Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.