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I'm beginning to see that the violence in my relationship is a problem.
I don't see the point of focusing on the violence in my relationship.
Although I haven't been violent in awhile, I know it's possible for me to be violent again.
I'm actively working on ending the violence in my relationship.
I wish I had more ideas about how to end the violence in my relationship.
I'm actually doing something to stop my violent behavior, not just thinking about it.
The violence in my relationship isn't a big deal.
I've ended the violence, but sometimes still struggle with the old urges that allowed the violence to happen in the first place.
It's OK to use violence as long as you don't hurt anyone.
I'm at a point in my life where I'm beginning to feel the harmful impact of my violent behavior.
I've made some changes and ended the violence, but I'm afraid of going back to the way I was before.
As far as I'm concerned, there's no need to change the way I treat my partner.
Although at times it's difficult, I'm working on ending my violent behavior in my relationship.
More and more, I'm seeing how my violence hurts my partner.
I'm finally doing something to end the violence.
I guess I have bad points, but there's nothing I really need to change.
I've been pretty successful in leading a violence-free life, but there are still times when I'm tempted to resort to violence.
I'm making important changes and ending the violence in my life.
More and more, I'm realizing that my violence is wrong.
Although I've made the changes necessary to lead a violence-free life, there are still times when I'm tempted to use violence.
Name
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First Name
Last Name
Gender
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Ethnicity
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Birth Date
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MM
DD
YYYY
Personal Email Address
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Phone
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(###)
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Is it ok for us to leave a voicemail at the above mentioned phone number?
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Driver's License Number (or state ID if no license)
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Driver's License State
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Your Current Address
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Please include the number and street.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Group Type
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Group Day/Time Preference
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General Population
-Monday 5-6:30pm
-Friday Group coming soon
High-Risk Population
-Tuesday 6:30-8:30pm
-Wednesday 6:30-8:30pm
-Thursday 6:30-8:30pm
-Saturday 10am-12pm
LGBTQ
-Wednesday 1-2:30pm
Men's Spanish
Wednesday 6-8pm
If applicable, in the space below, please list your top two group choices in order of your preference.
*The group you choose will be your group for all 27 weeks of the program
Who referred you to our program?
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Please provide your referral source's name and contact information.
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i.e. phone number, email address, specific court number
Has your referral completed our Referral Eligibility Form?
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What is your CID number?
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What is your SID number?
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What is your case number?
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Are you currently employed?
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Employment Type
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Annual Personal Income
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What is your highest level of education?
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Partner's Name
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First Name
Last Name
Partner's Gender
Partner's Ethnicity
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Partner's Birth Date
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MM
DD
YYYY
Do you and your partner currently live together?
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*The partner from the incident that led to your referral.
Do you have your partner's contact information from the incident?
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By answering "Yes" you will need to provide all information you have and are able to obtain. By answering "No" you are stating that you do not have the information, nor are you able to obtain the information.
Partner's Phone Number
(###)
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Partner's Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you live with a new partner?
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What is your marital status?
How many children, under the age of 18, live with you?
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Is there a current protective order out against you?
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When does the protective order end?
MM
DD
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Please describe your current/past alcohol/drug use.
Do you consider your current/past alcohol/drug use excessive?
Please mark each of the following that you have experienced:
Were you ever abused as a child?
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What did the abuse look like and from whom did you receive it?
Date of incident that led to your referral
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MM
DD
YYYY
Were drugs/alcohol used during this incident?
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Please describe the incident
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Please describe any other incidents of your past use of violence/abuse
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Please check any of these behaviors that you have participated in
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Click all that apply
Please check any of these behaviors that you have participated in
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Click all that apply
Have you ever harmed or neglected a child, even accidentally?
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If yes, please describe.
Have you ever harmed or neglected an animal or pet, even accidentally?
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If yes, please describe.
What kind of support network do you have in terms of immediate family, friends, coworkers, and/or religious community?
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Have you ever been to counseling?
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If so, for what?
Have you ever taken a substance use or mental health evaluation?
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If so, what was the outcome?
Do you hear or see things that others don't?
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If so, what do you hear/see?
Have you ever been to a drug or alcohol treatment or a treatment facility?
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If so, when?
If so, did you finish treatment?
I have read and understand these policies and my obligations as a PAIP group participant. I understand that failure to comply with any of these conditions may result in dismissal from a group session and/or being terminated from the program.
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I enter into this Agreement for Services with SafeHaven of Tarrant County (SHTC) for participation in the Partner Abuse Intervention & Prevention (PAIP) program.
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Please input the date that you are signing this document
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MM
DD
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