Place a checkmark, in each checkbox, ONLY if you have completely read, completely understood, and completely agree with the entire statement which immediately follows it.

Personal Information

Name: Date of Birth: Address: Phone Number: Email: Referred by: The personal information provided above is correct.

Confidentiality Notice

Regarding Client Records and Information

The confidentiality of client records maintained by this agency is protected by Federal Law and regulations. In general, this program may not state to anyone outside the program that a client attends the program, unless:

The client consents, in writing.
The disclosure is allowed, or required by court order.
The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program review.
Stated threat of harm to self or others.

Violation of the Federal regulations is a crime and may be reported to the appropriate authorities in accordance with Federal law.

The Federal law and regulations do not protect any information about a crime committed by a client either at the program, or against any person who works for the program, or any threat to commit such a crime. Nor does it the law protect any information about suspected child/elder abuse or neglect which must be reported under State law to appropriate State or Local authorities.

(Refer to 42 CFR Part 2 for Federal regulations, a copy of which may be obtained from the program office.)

I have read and understand the confidentiality notice regarding client records and information.

Contract for Participation

I understand that if I have been court ordered to attend this program, it has been documented that I have been violent. A requirement for participation in the program includes my taking responsibility for my actions and talking about my violence. In the event that I deny being violent, Anger Solutions will have no choice but to refer me back to court. I agree to attend a minimum of 8 group sessions with Anger Solutions. I understand that the group facilitator will report my attendance, acts of violence, and an evaluation of my progress to the court and/or their agents. I understand that any violation of conditions of the program or probation are grounds for removal from group and referral back to court. I understand that if I move, while I'm attending the program, I must notify this agency of change of address and that this program can only be provided within the state of Oregon, to Oregon residents. I agree not to be violent with any person during my participation in the "Coping With Anger" cognitive-behavorial program. I understand that missing a group or redoing a module counts as a "strike" and that after 5 strikes I will need to purchase a new workbook and restart the program. I understand that the work materials for "Coping With Anger" are my responsibility and that any lost or damaged materials will need to be replaced at my expense.

Fee Agreement

$20.00 ... "Coping With Anger" workbook
$50.00 ... One time on-boarding session
$30.00 ... Each group (8 to 12 sessions)

I understand that any additional groups are $30 each.

I understand fees estimates are based upon minimum requirements.

I understand fees will be higher if my further participation is required.

I understand that all fees are due at the time of service and I won't be admitted into group until the fee is paid.

I understand there are no refunds, for fees paid, if I am closed non-compliant due to violating program rules or the conditions of my probation / parole.

Group Rules & Expectations

The "Coping With Anger" anger management group is designed to assist each participant to develop an awareness of the impact of "anger" in their life, develop an understanding of what causes anger, and to provide each participant with some basic tools to manage anger more effectively. The treatment concepts and anger management tools presented in this group are evidence based and have demonstrated effectiveness in helping individuals manage anger. As with learning any new skills and behaviors, practice is an essential part of getting the most from this group. All participants must sign a Release of Information (ROI) form for their referring agent. If you are unwilling to sign an ROI or revoke your ROI to your referring agent then notification will be made to your parole/probation officer and/or referring agent and you will no longer be able to attend the group until you have discussed the issue with your parole/probation officer. Participant progress and attendance at each group is reported to the Court of supervision and/or responsible parole/probation officer. The anger management group meets weekly, at 6:30 PM. Group participants will need to purchase the "Coping With Anger" workbook, for $20, and read and complete Module 1 prior to the first group session. Participants are required to have their device plugged-in and their workbook, a pencil, and eraser with them, at each and every meeting. The "Coping With Anger" program can be completed in 8 sessions. However, if you do not complete your work to the satisfaction of voting group members and/or the group facilitator, you will asked to redo the work and re-present it the following week. Any additional group sessions will incur an additional cost of $30 per session, due before that sessions begins. A participant will not be admitted to a session or may be dismissed from a group session if:

They present as intoxicated or "high".
They become verbally disruptive and/or threatening during the group.

Participants will not be admitted to a session if they do not arrive prior to the beginning of the session and will not be given credit for the session if they leave before being dismissed, at the end of the session. If you are removed from a group session, it will count as one absence, and you will be permitted to return to the next group session after discussing the situation with your Court of supervision and/or probation officer. Redoing modules and/or failing to attend the weekly group 5 times (combined total) may result in "unsuccessful completion" of the program and notification will be forwarded to your Court of supervision and parole/probation officer. Participants are responsible for payment of all services. All fees must be paid at the time of service unless special arrangements have been made. Completion letters / certificates will not be issued with any outstanding fees. No violence or threats will be tolerated, and will result in the participant being immediately dropped from the program, and no refund will be issued.

I, , have read and understood and agree with all of the information presented and I've placed a check mark, in each relevant box, to indicate such.