Domestic Battery Intervention Application - Getting Started

Full Name: *

Email Address: *

Phone number you can be reached at: *

Probation / Parole Officer Name: (if unsupervised, write unsupervised) *

Probation /Parole Office (e.g., Canyon County Felony Probation, Ada County Domestic Violence Court, N/A). *

By clicking "Yes" below, I'm certifying I understand if I am required to do less than 26 sessions the therapist will need to consult with me before enrollment to verify program suitability and requirements. *

Today's Date: * +

This enrollment packet must be filled out to the best of your ability. Additionally the clinic must receive the following items to complete your enrollment: (If you are attending voluntarily, and do not have charges pending, you can attend for free, if you have charges pending, you can apply, but cannot finish enrolling until after your sentencing).

The $35.00 cost of the pretreatment appointment/enrollment (you do not have to pay to complete this application)

A copy of the police incident reports for the current charge as well as reports from any prior domestic batteries.

A copy of any NCO violation police incident reports (if you were charged with any),

A copy of your judgment / parole agreement / orders from your PO requiring treatment

A copy of your criminal history and domestic violence evaluation (if you had one done).

(look up the agencies and they will have info about how to request them or get them sent, they can be emailed to you and you can print them or send them to the clinic matt@affinitybeahvioralhealth.com)

If you have any questions, you can text or call 208-461-3720

You can see the privacy policy regarding text messages here: https://affinitybehavioralhealth.com/?page_id=56