Domestic Violence Program

Initial Contact

Program Contract

Waiver of Confidentiality

Promise to Maintain Confidentiality

Program Policy

Drug and Alcohol Assessment

Initial Contact and Intake

Have you ever attended another domestic violence program?

Yes No

Name of program:

How many sessions did you attended?

Do you have or can you provide documentation of your sessions, last date of attendance, progress, participation, and financial status from that agency

Yes No

Do you have a court order?

Yes No

Today's Date:

Referring Agency or Court and County:

Number of weeks required:

Case Information

Probation Officer/ Parole Agent/ Mediator/ Court Liaison:

Phone Number:

Fax Number:

Case/ File/ X-Reference Number:

Victim's Name:

I don't know the location of my victim.

Victim's Address:

City:

State:

Zip:

I, do hereby represent and warrant that I have no information whatsoever concerning the location or whereabouts of my victim. I make this representation under penalty of perjury. If this representation is false, I am aware that perjury is a felony pursuant to the California Penal Code and is punishable by state imprisonment.