DISCLOSURE OF LIMITATIONS OF CONFIDENTIALITY

DISCLOSURE OF LIMITATIONS OF CONFIDENTIALITY

I understand that the following may be exchanged by Family Peace Initiative Program (FPI) to "related agencies" listed below in the Community Response to Domestic Violence: 1- Assessment Findings, 2 - My Attendance, 3 - Any Use of Violence or Threats, 4 - Reasons for Suspension Termination, 5 - Recommendations Regarding Changes in Counseling, 6 - Completion or Graduation from the Program Due to the need to ensure safety and cooperation with courts. Confidentiality is limited in concern to the above. Please indicate that you have read and understand the above mentioned list.*

Yes I understand

No - I have questions and concerns

RELATED AGENCIES: 1. County, Municipal or District Court, 2. Court Officers - Probation, parole or community corrections, 3. Court DCF Caseworker 4. Juvenile Justice Authority Caseworker, 5. County Attorney and Staff, 6. Private Agency Caseworker (Family Preservation, Elm Acres, The Farm) 7. Domestic Violence Program 8. Law Enforcement Agencies (Police or Sheriff)*

Yes I understand

No I have questions and concerns

9. Other Collateral Contacts - Is there any specific individual that information should be exchanged with under this release?*

Yes

Name (Other Collateral Contact)*

Please provide the name of the contact that you are permitting us to exchange information with.

Agency/Relationship (Other Collateral Contact)*

Please provide the agency this individual works for or their relationship to you.

Phone Number/E-mail Address (Other Collateral Contact)*

Please provide either a phone number or email address for this individual

Additionally, I understand that this information may be exchanged with any victim, partner, and previous partners both for the purposes of assessment and safety planning for myself and my victim/partner. I understand that my case file and records may be reviewed by the Office of the Attorney General staff for the purposes of certifying the BIP program and understand that this could occur during and after my completion of this program.*

Yes I understand

No I have questions and concerns

I acknowledge that I have read and understand the above. I understand that my records are protected under certain governmental and ethical regulations and, other than what is mentioned above, cannot be released without my written consent or subpoena by a court of law. (Check Box Below)*

Case Files Uploaded

If there is an open case with an agency, we will need to obtain your case records. If you have them or if we have recommended that you make the request, you can attach here or you can send to Family Peace Initiative:

Email - reception@familypeaceinitiative.com.

Fax - 785-215-8144 or

Mailing address - 200 SW 33rd St. Topeka 66611

Drag and drop files here or

Participant Name Printed*

Participant ID

Sent with the email that you received. Example: SMA18199

Participant Name (E-Signature)*

Type your full name as you would use for signature

Participant Email Address*

Date*

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