I, ,
acknowledge that I have used violence (emotional,
physical, and/or sexual) that has hurt or made another person feel powerless.
- I will not abuse anyone else or myself as long as I am in this program. This includes
verbal,
emotional, sexual, financial, and psychological abuse; threats of suicide; and threats of
violence. If I
commit an act of abuse towards another person or myself, I will inform the program staff of
what
happened. I will openly talk about the situation and accept the consequences for my
behavior.
- I agree that the reason I am in the program is to learn not to be violent or abusive. I will
not be
violent or abusive in this group or in my personal life.
- I will participate openly, honestly, and actively in educational group discussions, and I
will abide
by all program group rules. If personal problems arise (e.g., drug abuse, mental health
issues) I
will seek appropriate treatment as a condition of my participation in the program. I will
voluntarily
cooperate if program staff requests that I obtain an assessment.
- I will provide the correct address and phone number of the victim of my violence and will
notify program staff of any changes.
- I understand that the safety of others and me is priority and will be enforced by the
program staff.
- I understand that all suspected child abuse and neglect will be reported as defined by
Indiana law.
- I understand that all suspected battery, neglect, or exploitation of an endangered adult
will
be reported as required by Indiana law.
- I understand that there may be visitors attending my group, including, but not limited to
shadowing staff, guest speakers, or substitute leaders.
-
My weekly fee will be
$
.
If I should become two weeks delinquent in fees, I may be expelled from the group.
- I will attend group on at .
Any changes
to the day and time of attendance will need to be approved by the group facilitator.