YOUR REGISTRATION INFORMATION

If you need help completing this form, please call (925) 432-4200.

Full name as it appears on your documents*

E-mail address*

Your Court, Case, Docket, or CDC Number

Your Address*

Your City, State and Zip*

Phone numbers*

Date of Birth *

Next court date (if applicable)

Please list details of any restraining orders, Stay-Away orders, etc.

Written Agreement (read each section, check "Yes" if you agree)

Read and agree to each statement, then sign at the bottom.

This is a written contract between myself and the Saving Our Sons and Daughters Batterers’ Intervention program. I understand that as part of my acceptance into the program I will continue to abide by the terms and conditions per the court order. I additionally agree to stay in constant contact with my probation officer and abide by her/his rules.
Yes

In addition, I understand each of the SOSAD rules and regulations and agree to abide by the policies of this organization. SOSAD has informed me that they will make contact with my (victim) partner. I agree that everything that is discussed between SOSAD and my partner is confidential, and I will never make any attempts to determine what was discussed or attempt to see any documentation that may have been generated between my partner and the SOSAD program.
Yes.

I am fully aware of my weekly or monthly class fees that are due at the beginning of class or the month. I agree to pay my class fees on time and if necessary, pay any late fees that are accumulated as a result of me not paying my fees on time.
Yes

I understand that SOSAD may need to communicate with the probation department and other departments and programs to effectively administer and maintain my case file during and immediately proceeding my time with the program. I agree to make every possible effort to assist SOSAD with obtaining necessary documentation that they request from me.
Yes

My initials will serve as my consent and waiver to obtain paper work necessary to maintain my file and effectively communicate with the probation department, courts or other programs and/or departments.
Yes

I fully understand the Virtual Meeting program as described. I further understand the SOSAD Administrator has the capability of recording (Audio/Video) any of these meetings and such recordings are the property of SOSAD and can be used for training and or administrative purposes. My initials indicate my understanding and consent.
Yes

SOSAD has been generous enough to provide me with the website: www.savingsonsndaughters.com, which allows me to go to the website and read the definitions for physical, emotional, sexual, economic, verbal, coercion and threats, using the children and techniques for stopping these types of abuse. I also understand I am obligated to download this information, study it weekly and bring a copy of this helpful information in my class binder weekly.
Yes

During my initial intake, I was told that violations on my part would possibly trigger the SOSAD program to request that I attend additional sessions. If the program decides to initiate this action, I will agree to attend the additional sessions and promise to correct the documented behavior problem.
Yes

The SOSAD program has explained that I will be held accountable for my acts or threats of violence in a relationship while I am attending the program and any such acts may subject me to termination from the program.
Yes

Further, I understand that if my behavior or actions do not approve, the SOSAD program may move to have me terminated from the program. I understand that before I am terminated, the director or assistant will meet with me and attempt to resolve any conflicts or problems that I may be having. The program has explained that if they decide that I am unsuitable to continue the program, they will notify me immediately.
Yes

I understand the importance of abiding by any lawful court stay-away order, emergency protective order, or restraining order. SOSAD has indicated to me that they take these orders very seriously and if they determine that a court order has been violated, they will take appropriate steps to notify the proper authorities.
Yes

Once I am assigned my start date, I agree to show up to all sessions on time. I further understand that if I am more than 10 minutes late, I will not be allowed to attend class and will be marked absent for the day.
Yes

I also understand I am expected to be in class and ready to go at the beginning of the class start time. Walking in class even a minute after the start time is considered late and if I accumulate 4 (four) times being late during the program, I will be required to attend a make-up class at my expense.
Yes

I understand the attendance policy is very strict and I am expected to attend every class weekly and on time. I further understand that if I miss (2) two consecutive classes without contacting the program, I will be terminated from the program.
Yes

I also understand that if I accumulate a total of (4) four absences during the program I will be terminated upon my fourth absent.
Yes

The program director has provided me with a cell phone number and I am fully aware that I must text him and leave a message if I am going to be late, absent from class, or have a work or travel obligation that will prevent me from attending my assigned class.
Yes

I understand that all excused and unexcused absences must be made up immediately to maintain my continuity with the program. I understand all makeup classes must be paid for in advance.
Yes

The SOSAD program has advised me of their strict policy regarding not being under the influence of alcohol or drugs while attending the program. The program has explained that if they feel that I am under the influence of drugs or alcohol they will ask me to leave the group session for that day. If for some reason I don’t agree with their assessment, I have the right to request an alcohol or drug test at my own expense. I understand that this test must be arranged and conducted within 90 minutes of the notification. All test results must be given to the program with the name and phone number of the person who administered the test.
Yes

As part of my in-take, I signed the Confidentiality statement prohibiting disclosure. I understand I will not release information that is considered private and confidential. I further understand that information that is obtained during the group session would often lead to information that reveals private information. I promise that I will not attempt to subvert the program by giving information about who is in the program or who their partner may be. If a participant of the program, or their partner is seen in public, clients of SOSAD are prohibited from talking about their knowledge of that individual attending the program, or their partner being the victim/survivor of a client in the program. All clients of SOSAD must protect the privacy of others!
Yes

The SOSAD program is dedicated to offering the clients the best educational program possible. The Duluth Model & Another Way… Choosing to Change has been accepted evaluated programs that has been used all over the country. We feel that our program along with our staff has excellent chemistry to best present this entire program to our clients. In addition to the program, it has been our experience that we often learn from each other and from personal experiences. Therefore, we will monitor material and personal experiences, and if it is determined that it is beneficial to the clients, we will continue to use the material. Remember our goal is to stop the violence and have the perpetrator rethink his/her abusive behavior. We are striving for a positive change in the individual that would keep him/her out of trouble with the law. We also want the victim to enjoy their rightful safety and no longer be controlled by the batterer. Everyone deserves to live a healthy and abusive free life, your job is to help us, help you get us there.
Yes

COMMUNITY RESOURCES

Are you are actively involved with any of the following programs? (please check all that apply.)
Mental Health ServicesParenting ClassesA.A. ProgramN.A. Program

Would you like to receive information on the following services?
Mental Health ServicesParenting ClassesA.A. ProgramN.A. Program

PROGRAM RULES

Here is a link to our program rules. Please check this box to confirm that you have read and understand the program rules.
Yes

CONFIDENTIALITY STATEMENT

Here is a link to our confidentiality statement. Please check this box to confirm that you have read and understand our confidentiality statement.
Yes

ONLINE CLASS POLICIES

Here is a link to our online class policies. Please check this box to confirm that you have read and understand our online class policies.
Yes

DEFINITIONS

Here is a link to the definitions of domestic violence. Please check this box to confirm that you have read and understand our online class policies.
Yes

TODAY'S DATE *