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Guidelines for Video Chat Support Group

Taking into consideration all the confidentiality issues with Video chat platforms. We created the following recommendations:

Do not join the conversation if you are any near your abuser.
We will only do the check in part, avoiding all comments about the development of divorce, custody or other legal matters.
Let's try to make sure our children are busy doing something else, if possible have everyone wearing headphones.

Disclaimer and Release of Liability

Bridges DVC offers online support group services via zoom to clients in special circumstances. These services are offered as the exception, rather than the rule. For clients who choose to utilize this method, the below information serves as informed consent and practice policies for these services.
The client will engage in online support group once they have made sure they are in a safe place to talk.
Bridges DVC will take all available precautions to protect the confidentiality of the client and the content of online support group sessions.
Neither counselor nor client will be allowed to video or audio record the sessions.
The potential risks for online service include: possible misunderstandings in tone of voice or body language when there are delays in the videoconferencing, computer glitches, technology failures and mistakes through human error.

I hereby release Bridges DVC of any liability in the event of an unauthorized caller getting access to the call.

Name(Required)

First Last

Date(Required)

Signature(Required)

BRIDGES Domestic Violence Center: Confidentiality Agreement

I understand that the women and children served by BRIDGES Domestic Violence Center are in dangerous situations. For their protection, it is critical that their identities and the location of the facilities, including that of Support Group, remain confidential.

By my signature, I agree to respect the confidentiality of BRIDGES Domestic Violence Center facility, staff, and the women and children BRIDGES serves. I will not reveal information about the identities of the members of support group, the identities of the members’ children, the identities of the staff members, or what is said in support group without then woman’s written permission.

In addition, I agree to respect confidentiality by not taking pictures of or recording (via audio or video) any portion of support group. If I need to take a phone call, I will step outside and do so in private.

Signature(Required)

Date(Required)

Name(Required)

Phone(Required)

BRIDGES Domestic Violence Center Release of Liability: Support Group

I, the undersigned, authorize any BRIDGES Domestic Violence Center staff or volunteer to transport me and my dependent(s) to the nearest medical facility in an emergency in which I am incapacitated or unable to care for myself and/or my dependent(s). I agree to let a doctor treat me and my dependent(s) for emergency care. This agreement finds BRIDGES Domestic Violence Center devoid of any liability in an emergency situation.

Signature(Required)

Date(Required)

I, the undersigned, authorize BRIDGES Domestic Violence Center staff or volunteers to transport me and my dependent(s) in a staff member’s or volunteer’s private vehicle, in case of emergencies, etc. This agreement finds BRIDGES staff or volunteers devoid of any liability in the event of an accident.

Signature(Required)

Date(Required)

I understand that BRIDGES Domestic Violence Center is not responsible for any personal injury that may occur to me or my dependent(s) while we are at support group. BRIDGES is not responsible in any way for any accidents and/or injuries that might occur through intervention and the outcome of my personal decision based on my involvement in any services offered by BRIDGES. BRIDGES is not responsible for any loss of my personal belongings while I am (we are) at support group.

Signature(Required)

Date(Required)

I, the undersigned program participant, understand BRIDGES Domestic Violence Center is required, by law, to report any suspected child abuse to the Department of Children’s Services. If I have knowledge of abuse, I understand that I will have the opportunity to call DCS first, and then the staff will call DCS.

Signature(Required)

Date(Required)

I give BRIDGES Domestic Violence Center permission to release my information in the event of a medical emergency or my death.

Signature(Required)

Date(Required)

I understand that BRIDGES Domestic Violence Center is required, by law, to release my records in the event of an authorized subpoena. Also, medical records if I am unable to speak for myself due to a medical emergency.

Signature(Required)

Date(Required)

Acknowledgment of Understanding of Surveillance: Support Group

I acknowledge that I have been made aware that the facility at which BRIDGES Domestic Violence Center’s Support Group takes place has a surveillance system for the purpose of protecting the safety of the people who enter said facility.

Name(Required)

Date(Required)

Signature(Required)

Do you require child care?(Required)

Yes

No

Children’s Support Group Intake

Date(Required)

Support Group

Guardian’s Information

Guardian’s Name(Required)

First Last

Relationship to Child(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family History

Mother

Father

Custody

Name of Abuser

Relationship to Children

Do children live in same home as abuser?

Children’s Information

1. Child’s Name(Required)

Age(Required)

Sex(Required)

D.O.B.(Required)

School Attended to Date

Grade

Allergies

Current Health Problems

Current Behavioral Problems

Has your child witnessed abuse in the past?

How often?

What type of abuse was witnessed?

Has your child been abused?

Abuser

When?

Describe the abuse

Do you have any specific concerns about your child?

Is there any other information that you think we would need to know about your child?

2. Child’s Name

Age

Sex

D.O.B.

School Attended to Date

Grade

Allergies

Current Health Problems

Current Behavioral Problems

Has your child witnessed abuse in the past?

How often?

What type of abuse was witnessed?

Has your child been abused?

Abuser

When?

Describe the abuse

Do you have any specific concerns about your child?

Is there any other information that you think we would need to know about your child?

3. Child’s Name

Age

Sex

D.O.B.

School Attended to Date

Grade

Allergies

Current Health Problems

Current Behavioral Problems

Has your child witnessed abuse in the past?

How often?

What type of abuse was witnessed?

Has your child been abused?

Abuser

When?

Describe the abuse

Do you have any specific concerns about your child?

Is there any other information that you think we would need to know about your child?

4. Child’s Name

Age

Sex

D.O.B.

School Attended to Date

Grade

Allergies

Current Health Problems

Current Behavioral Problems

Has your child witnessed abuse in the past?

How often?

What type of abuse was witnessed?

Has your child been abused?

Abuser

When?

Describe the abuse

Do you have any specific concerns about your child?

Is there any other information that you think we would need to know about your child?

Is there anything you need a referral for?

Counseling:

Medical:

Academics:

Other:

Bridges Domestic Violence Center: Release of Liability

I, the undersigned, understand that BRIDGES is not responsible for any personal injury that may occur to me or to my dependent(s) while we are participating in the Outreach Programs. BRIDGES is not responsible in any way for any accidents and/or injuries that might occur through my personal decisions or a decision made by my child/children based on involvement in any services offered by BRIDGES. BRIDGES is not responsible for any loss to my child’s/children’s personal belongings while I am (we are) participating in the Outreach Programs.

By signing below I also acknowledge that BRIDGES is required by law to report any suspected child abuse to the Department of Children’s Services. I understand that I will have the opportunity to call DCS first and then the staff will call DCS.

By my signature I also state that I have received a copy of the BRIDGES children’s support group guidelines and if at any time I have a question about those guidelines I will discuss that with the children’s group facilitator. The name/names of my child/children participating in the Outreach Program is/are listed below:

Children's Name(Required)

Signature(Required)

Date(Required)

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Intake Forms

Guidelines for Video Chat Support Group

Disclaimer and Release of Liability

Contact Information

Emergency Contact

BRIDGES Domestic Violence Center: Confidentiality Agreement

BRIDGES Domestic Violence Center Release of Liability: Support Group

Acknowledgment of Understanding of Surveillance: Support Group

Children’s Support Group Intake

Guardian’s Information

Family History

Children’s Information

Is there anything you need a referral for?

Bridges Domestic Violence Center: Release of Liability