Intake & Orientation

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Dutch Will Assessment Group is designed to help individuals take accountability for abusive behaviors and learn healthier ways to manage conflict and relationships. Participating in our classes is an essential step toward personal growth, fostering safety, and breaking the cycle of abuse.

How the Process Works:

  1. Step 1: Complete the Orientation Form
    After contacting us to get started, you’ve received a link to this page. This page is not publicly accessible and is specifically for you. Please fill out the orientation form below and submit it.

  2. Step 2: Confirmation Email
    Once you submit the form, you will receive a confirmation email letting you know that your form was received.

  3. Step 3: Submit Your Payment
    After the confirmation email, you’ll receive another email with a link to the payment page. Use that link to submit your intake payment.

  4. Step 4: Get Your Group Link
    Once your payment is received, we’ll send you a final email with the link to the group you selected in your orientation form.

Intake Orientation Form

Intake Orientation Form

This form is an Intake and Orientation document for the Dutch-Will Assessment Group’s Battering Intervention and Prevention Program (BIPP) & MRT. It outlines the program’s requirements, participant obligations, confidentiality agreements, and other essential information. By completing this form, participants acknowledge their understanding of the program's rules and commitments necessary for successful participation and completion.

Name
Name
First
Last
First
Last
Preferred Group Time

Statement of Confidentiality

I understand that all information about Dutch-Will Assessment Group LLC participants is confidential. I will not identify or discuss any identifying information pertaining to either a participant or victim (i.e., name, address, phone number, occupation, etc.) with anyone outside of Dutch-Will Assessment Group LLC staff volunteers and interns.
I understand that all of the above-mentioned conditions apply to me while I am participating, employed, volunteering and/or interning with Dutch-Will Assessment Group LLC and continue to be binding after my current working relationship with Dutch-Will Assessment Group LLC ends.
I have read and understand the above-mentioned information. Failure to honor this statement may result in possible prosecution.

Payment Schedule

Dutch-Will Assessment Group-BIPP requires participants to provide payment prior to receiving services.

Minimal payment will be required for you as it serves as a financial means of accountability for your abusive behaviors.

Dutch-Will Assessment Group-BIPP will operate on sliding scale pricing.

Income
Income Session Fee
$35,001 and up $35
$20,001-$30,000 $25
$15,001-$20,000 $15
$5,001-$15,000 $10
$1-$5,000 Dutch-Will Assessment Group-BIPP will work with participants to develop a session fee that is sensitive to participants who are significantly struggling financially.
Indigent/Unemployed Dutch-Will Assessment Group-BIPP will work with participants to develop a session fee that is sensitive to participants who are indigent and unemployed.

Dutch-Will Assessment Group-BIPP will not offer you additional fee-based services provided by either the organization operating or overseeing the accredited program or any of the program’s staff members.
Referrals for additional fee-based services or supplemental programming will be made by referral sources.
If I should experience any financial challenges throughout the program, I will notify my facilitator.

A $5.00 LATE CHARGE WILL BE ADDED FOR EACH CLASS NOT PAID FOR AT THE TIME OF SERVICE. NOT PAYING MAY RESULT IN AN ABSENT FOR THAT SESSION.

I understand Dutch-Will Assessment Group--BIPP fee structure and agree to abide by it.

Participant Agreement

This form describes the Dutch-Will Assessment Group’s Battering Intervention and Prevention Program (BIPP) and your responsibilities.
Please read this form carefully.

We suggest that you keep your copy of this document with other important papers at your home for reference if you have a question about our policies while you are participating in this program. You may also need to keep receipts each week for proof of attendance.

Dutch-Will Assessment Group-BIPP consists of a minimum of 24 weekly, 1.5-hour group sessions. Completion of this program is part of your court or probation-ordered mandate unless you are attending this program on a voluntary basis.

A. Accountability and Your Obligations

  • You will acknowledge your abuse and discuss incidents relating to your abuse during group sessions.
  • You will not bring weapons, firearms, or objects considered to be harmful to the building.
  • You will NOT use alcohol or illegal drugs while participating in this program.
  • You will NOT use violence, abuse, or threatening and controlling behaviors, including stalking and violation of a protective order.
  • You will adhere to the group session rules and any other rules agreed to by all participants.
  • You are expected to treat facilitators, other participants, and guests with respect.
  • You are expected to adhere to our attendance policy.
  • You are expected to stay current on your program fees.

B. Fees

  • The fee for assessment and orientation is $50.
  • The fee for materials is $15.
  • The fee per group session is based on a sliding scale.
  • Remit all fees by CREDIT CARD, CASH, OR CASH APP.
  • Group session fees are due at the start of each session. Dutch-Will Assessment Group-BIPP may refuse admittance without payment, which could result in the participant being counted absent. Fees will not be refunded when the service is delivered.

C. Attendance

  • You will attend and complete all 24 sessions to receive a letter of completion.
  • You will arrive on time. Participants arriving more than 10 minutes late will not be admitted into the session.
  • You will notify Dutch-Will Assessment Group LLC if you will not be able to attend the session.
  • More than (3) absences will result in your dismissal from the program. At dismissal, Dutch-Will Assessment Group LLC notifies the referring agency.
  • After being dropped, you will restart the program from session one. If six months have passed since the initial assessment, you will complete a new assessment.

D. Group Participation

You are responsible for your engagement in the program. You will discuss your violent behavior throughout the program. Dutch-Will Assessment Group LLC expects you to discuss your attitudes, feelings, beliefs, and behaviors. Participation includes taking part in discussions and exercises.

E. Group Rules

  • Participants will engage in group discussion, exercises, and activities in a respectful manner. This includes participating in a non-abusive, non-controlling, and non-intimidating manner toward other group participants, group facilitators, and guests.
  • Participants will show up on time and stay for the duration of the session.
  • Participants who are more than 10 minutes late will not be admitted into the session. This will count as an absence.
  • Participants will silence their cell phones for the duration of the session.
  • Participants will only refer to the victim by first name.
  • Participants will not attend a group session under the influence of alcohol or drugs.

F. Completion

  • Complete orientation and assessment.
  • Complete 24 sessions as directed by the program.
  • Make full payment of fees.
  • Comply with group rules.
  • Actively participate in group sessions.

G. Termination

  • Your choice to continue to abuse, which includes any threats or physical violence in any situation.
  • Your frequent and/or patterned use of manipulation or disruptive behavior during group sessions.
  • More than (3) three absences. You should contact Dutch-Will Assessment Group LLC if you must miss group.
  • Violation of program and/or group rules.
  • Non-compliance with program fees.

H. Confidentiality

Dutch-Will Assessment Group LLC requires you to acknowledge your abuse and discuss incidents relating to your abuse during group sessions. However, all group members sign confidentiality statements that prohibit disclosure of any information shared in-group sessions.

Observers may be present to audit and gather facilitation information to later provide feedback. Observers are required to sign a confidentiality statement acknowledging that the names of participants are not to be disclosed.

Dutch-Will Assessment Group LLC provides notification to the victim identified on your assessment form when you enter, exit, or are terminated from this program. No assessment or information disclosed in class will be reported to victims.

All staff, volunteers, and interns sign confidentiality statements acknowledging that all information including your name, contact information, abusive patterns, victims’ information and any other additional information contained within the file will be kept confidential UNLESS subpoenaed by law or if circumstances meet the limits of confidentiality outlined below.

  • Referral source or Participant Designated Entities
    Reports are sent once a month to the referring agency.
  • Texas Department of Criminal Justice-Community Justice Assistance Division
    Performing program assessments and other research.
  • Victims, Law Enforcement Officers, Referral Sources, Medical and Mental Health Professionals
    In the likelihood of imminent physical injury to oneself or to others, staff will take safety initiatives.
  • Texas Department of Family and Protective Services
    If the assessment or subsequent contact reveals the possibility of incidents of child abuse or neglect, or abuse of the elderly or disabled.

I. Communication

You are responsible for providing your facilitator with any updates to your address or phone number(s).

You agree to inform your facilitator of any violent incident or police call to your home resulting from a family disturbance.

J. Your Rights

You have the right to be treated with dignity and respect and to receive equal consideration regardless of your race, color, sex, national origin, source of income, age, physical condition, political beliefs, or sexual orientation.

You have the right to know how your participation is reported to a referring agent, goals and expectations, the expected length, and cost for the Dutch-Will Assessment Group LLC program. You have the right to a copy of your file and can request one in writing. In addition, you have both the right and the responsibility to participate in this program.

Dutch-Will Assessment Group LLC will make a reasonable attempt to provide services in participants’ primary language. If Dutch-Will Assessment Group LLC is unable to provide service in the participants’ primary language, Dutch-Will Assessment Group LLC will refer the participant back to the referral source.

K. Grievances

Dutch-Will Assessment Group LLC is dedicated to providing service in accordance with standards recognized by the Texas Department of Criminal Justice, Community Assistance Division.

If you feel you have not been treated fairly, please notify your facilitator or director. You may contact Executive Director Brenda Riley.

You may also contact the Texas Council on Family Violence, by calling (800)-525-1978 for further assistance.

L. Our Obligations

  • To respect your dignity and confidentiality as defined in this document, and to give you a copy of this document and other signed forms for your records.
  • To provide fair and humane treatment and services in a manner that you can understand.
  • A copy of all written agreements, confidentiality forms, and criteria for exiting the program (for both completion and termination) at the time of assessment.
  • To provide notification of any changes in group time and schedules.
  • To comply with anti-discrimination laws and all applicable state and federal laws.
  • Dutch-Will Assessment Group LLC will provide copies of the fee structure and group schedule.
  • Provide a copy of the participant grievance procedure.
  • Provide progress reports to a designated referral source regarding your compliance status:
    • An initial first progress report will be submitted to referral sources, if any, within five working days of the completion of assessment.
    • Additional progress reports will be submitted every month after completion or termination.
    • Immediately report (within 5 working days) any known law violation by the participant including any incidents of physical violence, and/or termination from the BIPP.
    • Dutch-Will Assessment Group-BIPP will provide copies of your progress reports, or a status and participation report, if requested.

Individualized Plan

Participants and facilitators are involved in the development of this individualized plan. This plan will provide you with information and beneficial referrals to other community agencies.

This individualized plan includes recommendations to the referral source for additional interventions in response to assessment information or observed participation in groups and referrals made to local organizations to address participants' unique needs.

Individualized plans may be revised based on the changing needs of participants.

Referrals:

Telehealth/Virtual Policy

We are pleased to announce Dutch-Will Assessment Group LLC is offering telehealth/virtual services to our clients who wish to take advantage of this service.

Virtual services will allow the client to attend weekly group sessions in the privacy of their home, enabling the client to keep all scheduled meetings and stay in compliance with DWAG LLC program rules and meeting the conditions of probation, parole, CPS, or your attorney’s recommendation.

Telehealth Privacy for Patients

Telehealth is a safe and secure way of connecting with your health care provider online. Just like in-person care, your telehealth appointments, messages, and information are protected by privacy rules.

Privacy During Your Appointment and Rules

  • Your health care provider will call you from a private setting such as their office or an appointment room. You should also be in a private, safe location where you feel comfortable openly discussing your health.
  • Private locations for your appointment include:
    • A private room of your home
    • Your car
    • A private room in a friend’s home
    • Outdoors, away from other people
  • You cannot be at work (clocked in to your job) while on Zoom meetings with DWAG LLC.
  • You cannot drive a vehicle while on Zoom meetings.
  • You cannot use Zoom filters or a photo of yourself while on Zoom. You must be live.
  • You cannot be on mute unless asked to mute yourself.
  • You must actively participate. You cannot interrupt another participant while that person is speaking or “out talk/talk over” another person.
  • You cannot eat, drink, or smoke while on Zoom.
  • You cannot talk to another person, another co-worker, a family member, spouse, or partner as this will break confidentiality for other participants.
  • You cannot be in a public place while on Zoom, such as grocery stores or public parks.
  • You must always wear clothes.
  • You cannot be in your bed or lay down during Zoom meetings. You must always be in an upright position.
  • You cannot use offensive language, such as but not limited to, calling others a genital organ or using degrading and offensive language toward women (e.g., “This person is weak like a girl.”).
  • Logging in more than 15 minutes late to a Zoom meeting will result in an absence. Just as if you were in person, if there are technical difficulties for any reason, adjustments will be made.
  • Participants must pay before the session begins.
  • If you cannot find a private place for a video telehealth appointment, please let the facilitator know.

Before the Start of Your Appointment

  • Find a well-lit spot. Make sure there is good lighting so your health care provider can see your face.
  • Make sure the camera is steady. Set your computer or laptop on a flat surface or prop up your phone or tablet on a desk or table.
  • Make sure you are in the middle of the screen and the camera is at eye level. What you see on your screen is the same thing the provider will see, so it is important to make sure that you are close to the screen and looking straight into the camera.
  • Reduce background noise. Find a quiet place and reduce any distractions. Turn off alarms and sounds on other devices.
  • Close other applications. Close other applications on your device to improve your internet connection and reduce distractions.
  • Your name must be shown on screen—no nicknames, no cellphone names, or cellphone numbers.

Preparing for a Virtual Visit

For your telehealth visit, you will need a device that has video and an internet connection, such as a smartphone, computer, or tablet.

Be sure to be properly dressed as if you were in-person. If you are not properly dressed (e.g., no shirt), this could jeopardize your privilege to virtual sessions. Be sure to be in an upright position, not lying down in bed.

Recommendations for a successful visit:

  • Choose a private spot. You will want to be able to discuss your health care issues in private.
  • Stay focused. Try to avoid eating or drinking during your appointment. Do not do a telehealth visit while you are driving or running errands.
  • Be patient while waiting for your visit. Just like a regular in-person office visit, providers sometimes run behind schedule.
  • Be sure to write down any questions or concerns prior to or during your visit. This will ensure that you and your counselor address any thoughts or feelings you may have, such as but not limited to relapse prevention, cravings, triggers, goals, etc.

Please remember clients are not allowed to miss more than three group sessions per policy.

By signing below, you agree that you fully understand and agree to these terms and rules for the DWAG LLC program.

By clicking Submit, I acknowledge the information on this form has been reviewed with me and I understand and agree to the conditions of the Dutch-Will Assessment Group LLC outlined above and acknowledge that I have received a copy of this agreement. Failure to comply with these agreements and rules may result in my termination from the program and, if court-ordered, legal consequences.

Our experienced and highly trained staff is dedicated to helping individuals make positive changes in their lives. We believe that everyone deserves a second chance and that through education and intervention, individuals can make lasting changes to improve their lives and the lives of those around them.

Contact:

info@dwagbipp.org

 

409-658-8384

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Address:

200 South 10th St.

Suite #11

 

Richmond, Texas

77469

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