Orientation Paperwork

Step 1 of 5

Men’s Nonviolence Program Fees
The fee for participation in the Men’s Nonviolence Program is $540. -- This fee must be paid to complete the program and receive a completion letter.*
I have read and understand this statement
If the fee is not paid within 30 days after the completion of the program, your account will be turned over to collections.*
I have read and understand this statement
Please note - Once you have completed and paid in full, you can continue coming to groups for free or come back if it’s been within three years and you are NOT court ordered or sent here through a government agency.*
I have read and understand this statement
If you choose to pay all of it in advance and live in St. Louis County (Minnesota), you will get a discounted fee of $440 (a $100 discount).*
I have read and understand this statement
DO NOT make a payment until AFTER you have gone through the orientation process with DAIP's Men's Group Coordinator, Pat*
I have read and understand this statement
SUSPENSION POLICY
DAIP charges a $50 re-enrollment fee for reinstatement after suspension from the program. The fee must be paid on or before the re-enrollment date and all other payments must be current. You may be suspended if you are three or more payments behind.*
I have read and understand this statement
I understand that if I am suspended, I am not guaranteed an immediate return to my group.*
I have read and understand this statement
Participants Signature - Type your name below*
First Last
Date*
Month
Day
Year

If you have questions or concerns, contact Pat at 722-2781 ext. 106. E-mail PGoodman@TheDuluthModel.org
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RELEASE OF INFORMATION
I understand what is said in class may be shared with employees of DAIP. Additionally, the following information may be exchanged with the education team and referring agency working with DAIP.

My attendance.

Any use of violence or threats.

Reasons for suspension or termination.

Recommendations regarding changes in programming.

This information may also be exchanged with Arrowhead Regional Corrections and/or court representatives of*
Carlton County
Douglas County
St. Louis County
City of Duluth
Pastor/Church
Social Services
Other
Who else would you like this information to be shared with?*

I understand that records are kept confidential (except the limitations spelled out in the Contract for Participation and in this Release of Information) due to the commitment of the DAIP to the participant and will not be released without your written consent or unless subpoenaed by a court of law.*
I have read and understand this statement
DAIP is an international training center and because of this, visitors to our program will observe many aspects of our work including men’s programming. -- All visitors to our program are told about our commitment to keeping in confidence what is said in class unless there is a threat to harm oneself or another (as stated in the Contract for Participation). The visitor’s purpose is to observe how we facilitate the classes. - We also have employees of the DAIP who observe for training purposes. Each participant is expected to participate as usual when an employee of the DAIP is observing.*
I have read and understand this statement
This release of information is valid for 2 years. - All signed documents including this Release of Information will be destroyed after 5 years.*
I have read and understand this statement
The following agencies are members of or have representatives as part of the Domestic Abuse Intervention Project education team:

Dabinoo’Igan

Changing Men, Changing Lives

Domestic Abuse Intervention Program

Human Development Center

Duluth Vet Center

Men As Peacemakers

Arrowhead Regional Corrections

Duluth Family Visitation Center

Safe Haven Shelter for Battered Women

Execution Date*
Month
Day
Year

Participants Signature - Type your name below*
First Last
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ORIENTATION ASSESSMENT FORM
Todays Date*
MM slash DD slash YYYY

Name*
First Middle Last
Your Date of Birth*
Month
Day
Year

Cell Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County*

Email*

Ethnicity / race

Are you a US military veteran?*

Yes

No
Are you employed?*

Yes

No
Employer

Work phone
Have you been involved with the Domestic Abuse Intervention Program (DAIP) before?*

Yes

No
How did you come to DAIP this time?*

Probation

Protection order

Voluntary

Social Services

How many children currently live with you?

Ages of the children living with you?

How many children does your partner have?

How many children do you have together?

Law enforcement/Court Involvement
Have the police been called to your home because of a violent incident with the above named victim?*

Yes

No
How many times?

Were you arrested for the most recent incident?*

Yes

No
Were you given a ticket?*

Yes

No
Have you been arrested in the past for a violent crime?*

Yes

No
Are you on probation?*

Yes

No
How long is your probation? (In number of months)

Who is your probation officer?

What are your probation conditions? (Please choose all that apply.)*
DAIP
Stay away from victim
Fine
Abstain from alcohol
Chimerical dependency/alcohol evaluation
No same or similar offences
Supervised visitation
CD evaluation? **Please type in where in the space below.
No probation conditions
Please provide location of CD evaluation

Please provide any other conditions of probation here.

**Is there an Order for Protection (OFP) against you?*

Yes

No
Date of order
Month
Day
Year

Length of order?

Please provide name of the Judge

Conditions of order. (Please check all that apply.)*
DAIP
Excluded from Residence
No Contact
Contact only for visitation
Use the Visitation Center
Supervised visitation
No further abuse
CD evaluation? **Please type in where in the space below.
No court orders
Any other conditions not listed above? Please include them in the space below.

1. Have you ever been to counseling for abusive behavior?*

Yes

No
2. Please describe your current alcohol/drug use?*

3. Do you think your current alcohol/drug use is excessive?*

Yes

No
4. Have you ever had a chemical dependency or alcohol assessment?*

Yes

No
5. Have you ever been to chemical dependency or alcohol treatment?*

Yes

No
...If so, did you complete that treatment?*

Yes

No
**When will I start attending group? - You will be contacted by the DAIP Men's Group Coordinator when a space is open and available. Due to Covid-19 restrictions we have a waiting list. Pat will contact you when a spot becomes available and you are next in line. - Submitting your completed "Orientation Paperwork" secures your place in line. ** If you have additional questions you can contact DAIP Men's Group Coordinator - Pat Goodman, Phone: 218-722-2781 ext. 106 - Email: pgoodman@theduluthmodel.org*
I have read and understand this statement
Long-term contact information
We would like to contact you in 18 months to follow up and see how you are doing. Because people move frequently, we would appreciate it if you would give the name and address of someone who would always know how to reach you or forward mail to you.
Their Name
First Last
Relationship to you?

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

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

Step 1 of 5

Any information that is not filled out could delay your intake, and your referring agency will be informed (for example, Probation).

End page 1

MEN'S NONVIOLENCE PROGRAM RULES AND GUIDELINES

END PAGE 2

Men’s Nonviolence Program Fees

SUSPENSION POLICY

END PAGE 3

RELEASE OF INFORMATION

END PAGE 4

ORIENTATION ASSESSMENT FORM

Law enforcement/Court Involvement

Long-term contact information