Free for Life Mental, Emotional, & Behavioral Health Services

I understand that any information concerning the clients of the Free for Life Group Batterers Intervention and Prevention Program (BIPP) is to be kept strictly confidential at all times and I will discuss this information only with Free for Life BIPP staff. *

I Agree

I understand and agree that I shall respect the privacy of clients and hold in confidence all client information obtained while in the course of my professional service, interaction and observations with the Free for Life BIPP program. *

I Agree

Name: (Electronic Signature) *

Entering your name constitutes your electronic signature

First Name

Last Name

Date *

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Agency Representative: *

First Name

Last Name

Date *

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