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Registration Form
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Name
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First
Middle
Last
Address
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Street Address
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City
State / Province / Region
ZIP / Postal Code
Email
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Phone
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Have you been involved with a Batterers Intervention Program Before?
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Yes
No
How did you come to this Batterers Intervention Program?
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Probation
Protection Order
Voluntary
Other
Other
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Have the police ever been called out to your house for a violent or abusive incident?
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Yes
No
How many times?
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Have you been arrested in the past for a violent crime?
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Yes
No
List of Arrests
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Arrest Date
Reason For Arrest
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Remove
Who is your Parol Officer or Attorney? (Please input N/A if this does not apply to you)
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Parole Officer/Attorney Phone # (Please input N/A if this does not apply to you)
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Case Number (Please input N/A if this does not apply to you)
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What are your probation conditions? (Check all that apply)
Batterers Intervention Program
Stay away from victim
Abstain from alcohol
Chemical dependency/alcohol evaluation
No same or similar offenses
Fine
Any other conditions of probation?
Is there an Order of Protection against you?
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Yes
No
Date of Order
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Month
Day
Year
Length of Order
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Judge
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What are the conditions of the order?
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Have you ever been to counseling for abusive behavior?
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Yes
No
Please Describe your current alcohol/drug use?
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Do you think your current alcohol/drug use is excessive?
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Yes
No
Have you ever had a chemical dependency or alcohol assessment?
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Yes
No
Have you ever been to chemical dependency or alcohol treatment?
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Yes
No
Did you complete this treatment?
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Yes
No
Are you currently taking any medications?
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Yes
No
Please list the name and purpose of the medication:
Medication
Purpose
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Have you ever been diagnosed with a mental health condition and or treated for one?
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Yes
No
If yes, please describe:
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Zoom Meeting Contract
Log on to the meeting at least 10 minutes early before the start time so any
technical issues may be resolved before class
Once you log in and put your name in, you will need to agree to using video and audio.
If you need to discuss a personal issue with the facilitator, please ask the facilitator to stay after class.
Be sure to keep your video on during the entire class. If you do not, you can be removed from the group for lack of participation.
Keep the camera on your face. If we do not see you, we assume you are not there and paying attention, so you run the risk of not receiving credit for the class.
Be sure that you are alone during the class. No children, victims, or partners, etc.… should be with you in class.
You cannot travel during class. If you start to travel during class, you will be removed from class.
You are required to treat this class the same as if you were in person, which means being off work during class time and not doing other things like cooking or taking care of children. If you cannot do it while in class in person, then you cannot do it on Zoom. If you are doing any of these during class, you will be removed from group and not receive credit for the class.
Make sure you are prepared, sitting up and attentive during the entire class.
Your attention and participation are required. If you fall asleep or have side conversations, you will be removed from class and will not receive credit for the class.
You can also respond in the chat box if you have any audio issues. You must respond to the facilitator when asked a question.
You must be present and attentive for the entire class to receive credit. You cannot come in late or leave early to receive credit for class nor will you be able to come in and out of the room unless experiencing technical difficulties.
By affixing my signature, I fully understand the expectations of participating via Zoom in the Batterer’s Intervention Program (BIP) and that non-compliance could lead to dismissal.
Signature
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