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N. David Hubbard, LMHC, PL

CONTRACT FOR PARTICIPATION IN

ANGER MANAGEMENT PROGRAM

  1. I understand that I will not be allowed into the program if I am uncooperative with the assessor by refusing to provide information, either verbal or written, or if it is assessed that I may pose a risk tostaff and other participants of thegroup. The determination to reject someone from services may be based on such factors as level of uncooperativeness, intimidating behavior and a substantial criminal and/or violent history.
  1. I have been informed that in this group I will be held accountable for all abusive and violent behavior. I will be expected to describe in the group abusive and/or violent behaviors that I have used against others and will focus only on my own behaviors. Downgrading or blaming the victim will not be tolerated.
  1. I will attend the required8-12 group sessions, each one lasting 1 – 1.5 hours long. I must will make up any groups I miss. I understand that I will not be given credit for any group that I do not participate in, fail to complete written assignments for, that I did not attend entirely, disrupt, or do not cooperate with the therapist.
  1. I understand that it is expected that I will attend group sessions each week on a consistent basis until I complete the program. If there is an emergency that interferes with me attending I will contact my group therapist and whoever referred me, preferably prior to my absence but no later than the day of my absence, to explain the reason I am unable to attend. If I fail to notify my group facilitator of my inability to attend and/or if my absence from the group is not deemed “excusable” by my grouptherapist then I will be considered absent, unexcused. When possible I will also supply my group therapist with documentation that corroborates the reasons for my absence such as a doctor’s excuse. Two or more unexcused absences during the 12-weeksmay result in termination from the program.
  1. I will not attend group under the influence of drugs or alcohol. I will inform my therapist if I am taking any medication that could result in impairment. If it is determined that I have an alcohol or drug problem that is hindering my participation I may be terminated and referred for substance abuse treatment.
  1. I agree to arrive in sufficient time to pay my fee and begin group on time. I understand that once group begins I will not be allowed to enter that class.
  1. I will observe confidentiality by not revealing any information about other group members outside of group and I will insure cell phones are turned off during group.
  1. I understand that the following will be reported to the appropriate persons, including the victim, courts or probation, or other referral sources: Any serious threats that I may make to do bodily harm to the victim or any other person; a threat to commit suicide; any belief that child abuse or neglect is present and has occurred, which also will be reported pursuant to section 415.504, Florida Statutes.
  1. I understand that this program is under a continuing obligation to disclose any conduct I willfully choose to engage in which poses a threat to the victim, his or her property, or to a “third person related to the parties”. [For example, continuing Duty to Disclose Information, Fla.R.Cr.P. 3.22(j).] Any admissions of violence while in the program toward others will be disclosed to the referral agency and may result in termination from the program.
  1. I will not use sexist, racist or homophobic language or other abusive language in class.
  1. I will schedule and attend a dischargesession with my therapist the week after my last group session. At that time my progress, mental health & coping will be assessed. A completion summary, including recommendations for further treatment, if needed, will then be provided to the agency that referred me.
  1. I agree to alert my facilitator immediately if I have thoughts of hurting others or myself.
  1. I understand that intimidation, threats or other forms of disrespect toward my therapist, other staff or group members will not be tolerated and may result in automatic termination.
  1. If my participation in the program is below the required standard I will be required to attend an individual session in order to discuss areas that need improvement and to develop a compliance plan. If fail to attend this session I may not be given credit for further group sessions that I attend. This also applies if I am engaging in behavior that may place others or me at greater risk.
  1. I may be terminated if I violate any part of this agreement. Any failure to comply with this contract will be reported to the referral source within three (3) working days.

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Client NameSignatureDate

N. David Hubbard, LMHC, PL 1593 Co. Hwy. 393 S., Santa Rosa Beach, FL 32459Telephone: (850) 307-5273