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MONTGOMERY COUNTY ABUSE INTERVENTION PROGRAM – NEW BEGINNINGS

Please read through, fill in and sign this entire document.

You are not required to use this electronic signature medium to participate in the program and may request to come in person to sign hard copies.

Date of Birth


Electronic Communications

Please fill in your mobile phone number and email address below if you would like to request that we contact you via text and/or email (OPTIONAL).

Please read the notice on electronic communications here.

Notice of Privacy Practices

Please read the Montgomery County HHS Notice of Privacy Practices here.


STANDARD PROGRAM PARTICIPANT’S CONTRACT

The New Beginnings partner abuse counseling program is for individuals who want to not be abusive to their intimate partners and want to end all domestic violence in their relationships. The program offers an opportunity to share with others who have similar problems and learn how to recognize and avoid abusive behavior, how to communicate better, and how to build equal and satisfying relationships. Participants have chosen to attend the New Beginnings partner abuse counseling program voluntarily or to fulfill counseling requirements set by an agency such as the District or Circuit Court, Parole and Probation, Montgomery County Department of Corrections, or the State’s Attorney’s Office.  
 
By signing this document, I agree to the following Program conditions:
 
I. The participant’s partner/the petitioner will be notified of the participant’s referral to the Abuse Intervention Program, attendance and completion of/failure to complete program requirements.  The information about the participant provided to the petitioner will be strictly limited to these specific areas (for example, s/he cannot be told what the participant says in counseling, unless there is a threat of danger to the petitioner). Participants are expected to sign a consent for release of information to this effect.  The petitioner will be contacted by program staff in order to present her/his account of violence in the relationship and to be informed of APP services available. 
 
II. If a client is referred by a court or court-related agency, the referring agency will be notified in writing of the participant’s compliance or noncompliance with the program and the reason for that determination.
 
III. Participants are expected to acknowledge that abuse is inappropriate and criminal behavior and to be committed to learning non-violent strategies for solving problems between people.  Participants who are unwilling to make such a commitment will be dismissed from the program.  New incidents of abuse will be treated seriously by the Program, requiring additional counseling.  The criminal justice system also has in place penalties for such re-abuse.
 
IV. Fees: Fees for individual or group counseling are according to the Montgomery County Health and Human Services APP fee schedule and are based on cost of the service and a client’s ability to pay. Participants are required to pay $20 per group session unless they qualify for a fee reduction. Fee reductions can only be obtained by submitting documentation showing participant’s income. No fee reductions will be processed without such documentation.   
 
Participants who fail to pay fees on schedule or who do not accurately report family income may be dismissed from the program. Failure to pay fees (except in emergencies) will be considered non-compliance with the program. Fees are not charged for missed sessions.
 
V. Timeliness:  Participants are expected to be on time for all sessions.  Participants who arrive later than ten minutes after a session begins will be considered absent.  
 
VI. Confidentiality: All counseling is confidential.  While we encourage participants to practice communication exercises, the names and situations of other group members must not be shared with anyone outside the group.  The leaders will break confidentiality only in cases of imminent harm to self or others, or in the case where abuse of a minor or vulnerable adult is reasonably suspected.
 
VII. Cooperation/Disruptions: The leaders have the responsibility to remove from the group anyone they believe is not benefiting from group participation or who is interfering with the group’s progress.  Such removal will be addressed with each participant and may lead to dismissal from the group. All electronic devices must be turned off when entering group. No one under the influence of alcohol or drugs will be admitted to a session.
 
VIII. Session Attendance: Group participants are assigned to a Phase 1 Group which meets the same night each week for 6 weeks.  After completing Phase 1, participants are then assigned to a Phase 2 group.  Attendance in Phase 2 will be a minimum of 16 weeks.  Each meeting is 1 and 1/2 hours long.  Participants may be excused for up to 6 absences at the discretion of the program director. However, all clients must attend 6 sessions in Phase 1 before moving to Phase 2 and 16 sessions in Phase II in order to be compliant with the program. 
 
Participants will be dismissed from the program if they miss more than 6 sessions during their time in the program and will be required to restart the program from Phase 1 if they wish to complete it. 
 
It is the responsibility of the participant to notify the program if they cannot attend groups for some reason. If a participant does not attend for 3 consecutive weeks without contacting the program, they will be dismissed from the program.
 
IX. The intake counselor has the responsibility to determine if any additional services (e.g., substance abuse, psychiatric medication, etc.) or evaluation is necessary in addition to the Abuse Intervention Program.  Failure to comply with the counselor’s recommendations will result in dismissal from the program.  
 
Additional Rules for Online Groups
  1. You must be online, on time, and awake for the entire group time, with your video on and face visible.
  2. Do not engage in other activities during group time (e.g.: texting, social media, e-mail, games, etc.)
  3. You must be in a private area, without other people present if at all possible. If you cannot be alone, we ask that you use earphones in order to protect the confidentiality of others.
  4. You must be sitting down during group, not walking or lying down. You may not be driving during group.
  5. Do not have children or pets in the room with you.
  6. Do not smoke or eat during group. You may drink non-alcoholic drinks.
  7. You must be dressed as if you were attending group in person.
  8. No audio or video recording of any of the online sessions by any party is permitted. 
  9. You must be physically located in Maryland while participating in group (even if you are participating virtually).

Program Acceptance

Release of Information

The following releases of information are required in order to participate in the program. 


Release of Information - Referring Agency

I permit the Abused Persons Program to send/receive information to/from the below agency about my participation in the program, to facilitate assessment and coordination of services, including:

  • Acknowledgment of receipt of services
  • Complete program record
  • Alcohol or other drug treatment records
  • Records sent to DHHS from other providers and contained in the program record

This authorization is valid until the final disposition of case(s) for which client was referred to program.

I understand I can revoke this authorization at any time by submitting a request in writing to DHHS program staff. The revocation will become effective on the date it is received by DHHS and does not apply to information that has already been used or disclosed through this authorization. DHHS may not condition treatment, payment, enrollment or eligibility for services/ benefits based on whether I sign this authorization, unless authorization is required to determine eligibility for services/benefits. I understand that if the persons or organizations I authorize to receive and/or use my health information are not subject to federal or State privacy laws, this information may no longer be protected and could be disclosed. I understand that if this authorization pertains to alcohol or other drug treatment records protected by federal regulations at 42 C.F.R. Part 2, I can orally revoke this authorization, and my records may not be redisclosed without my written consent or as permitted by the regulations.

Please select the agency that referred you to the program:


Release of Information - Complainant

I permit the Abused Persons Program to send/receive information to/from the below individual about my participation in the program, to facilitate assessment and coordination of services, including:

  • Acknowledgment of receipt of services
  • Complete program record
  • Alcohol or other drug treatment records
  • Records sent to DHHS from other providers and contained in the program record

This authorization is valid until the final disposition of case(s) for which client was referred to program.

I understand I can revoke this authorization at any time by submitting a request in writing to DHHS program staff. The revocation will become effective on the date it is received by DHHS and does not apply to information that has already been used or disclosed through this authorization. DHHS may not condition treatment, payment, enrollment or eligibility for services/ benefits based on whether I sign this authorization, unless authorization is required to determine eligibility for services/benefits. I understand that if the persons or organizations I authorize to receive and/or use my health information are not subject to federal or State privacy laws, this information may no longer be protected and could be disclosed. I understand that if this authorization pertains to alcohol or other drug treatment records protected by federal regulations at 42 C.F.R. Part 2, I can orally revoke this authorization, and my records may not be redisclosed without my written consent or as permitted by the regulations.


Release of Information - Maryland Governor’s Family Violence Council

I permit the Abused Persons Program to send/receive information to/from the Family Violence Council about my participation in the program, to facilitate assessment and coordination of services, including:

  • Acknowledgment of receipt of services
  • Complete program record
  • Alcohol or other drug treatment records
  • Records sent to DHHS from other providers and contained in the program record

This authorization is valid until the final disposition of case(s) for which client was referred to program.

I understand I can revoke this authorization at any time by submitting a request in writing to DHHS program staff. The revocation will become effective on the date it is received by DHHS and does not apply to information that has already been used or disclosed through this authorization. DHHS may not condition treatment, payment, enrollment or eligibility for services/ benefits based on whether I sign this authorization, unless authorization is required to determine eligibility for services/benefits. I understand that if the persons or organizations I authorize to receive and/or use my health information are not subject to federal or State privacy laws, this information may no longer be protected and could be disclosed. I understand that if this authorization pertains to alcohol or other drug treatment records protected by federal regulations at 42 C.F.R. Part 2, I can orally revoke this authorization, and my records may not be redisclosed without my written consent or as permitted by the regulations.

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File Uploads

These are recommended but not required.

Please upload a photo of your ID

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If you have been referred by Pretrial Services, please upload a photo of your blue card.

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Please upload any other relevant documents (e.g., court papers).

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If you wish to apply for a fee reduction, please upload a proof of your income (pay stub, tax document, etc.). If you are being supported by someone else and have no income, you can have them sign a letter of support (below). Please note that you will be required to pay $20 for every session until such proof is provided.

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The letter of support can be accessed and signed here.

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