Abuser Intervention Program Registration / Online Intake Consent

Abuser Intervention Program Registration / Online Intake Consent
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example@example.com
I am requesting an intake because I am court ordered, pre-trial, or voluntary to enroll in SARC’s Abuser Intervention Program. I understand and agree to the following:

I must provide my name, phone number, address, and email address so that the agency can contact me to schedule a virtual intake. I consent to have the agency contact me via email, phone, or mail.

I will pay the intake fee of $65.00 via the Pay Now link at https://www.sarc-maryland.org/abuser-intervention/ to complete my registration. I understand this fee is non-refundable.

I understand that if I miss this appointment without giving notice 24 hours in advance, I will forfeit this fee. To be accepted into the program I will then have to reschedule and submit an additional $65.00 for the rescheduled intake appointment.

I understand that if I have been previously terminated from the Abuser Intervention Program at SARC, I must pay in full any remaining balance in order to be eligible to re-enroll. I understand that to re-enroll I must also provide a referral signed by my Probation Agent or an updated Court Order (if applicable).

I will provide the following documents for my intake as requested: photo ID, proof of income or unemployment, and Court Order, Statement of Charges, or Protective Order (if applicable). I understand that I will not be able to complete the intake process without providing the requested items.

I will provide accurate contact information for the identified victim, and agree to allow the agency to contact the victim per program requirements.

I understand that any threats or threatening behavior, verbal, physical, or sexual in nature, directed towards SARC staff is grounds for immediate termination.

The following are authorized to receive information regarding my involvement in the intake process for SARC’s Abuser Intervention Program:
Select all that apply:

Harford County Parole & ProbationCircuit Court of Harford CountyDistrict Court of Harford CountyAlternate County CourtAlternate Parole & Probation
If alternate, please specify:
I am choosing to participate in a virtual intake via Zoom. By choosing this option, I understand that I must use a computer, tablet, or smartphone with video and audio ability.

Due to the pandemic public health crisis of the Coronavirus, COVID-19, it has become possible for intakes and group sessions to occur via interactive video-conferencing (i.e. virtual “face to face” sessions) in lieu of “in-person” groups. Online group sessions will end after COVID-19 mandates are removed and SARC permits in-person groups to resume.

SARC has made every reasonable effort to implement technical security measures that reduce risks of a confidentiality breach. I understand the risk and I agree that SARC and my facilitator should not be held responsible if any outside party gains access to our zoom group.
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