Client information Part 1 of 6
Client information Referral / court information Program participation agreement Part 2 of 6
Program participation agreement Conduct, attendance, confidentiality, and court communication
You are enrolling in Secure Choices LLC services, including the 12-week Anger Management Course when selected. The anger management program is facilitated by qualified staff and is recognized as a court-ready educational program. Participants may receive materials and a completion certificate when requirements are met.
Court-ordered disclosure: if you are attending because of a court order, probation, parole, pretrial supervision, attorney referral, or other legal requirement, Secure Choices LLC may share attendance, progress, compliance, completion, non-completion, and safety-related concerns with authorized referring parties.
Authorized court / probation / parole / attorney contacts
Participant rules — initial each item Consent and signature Secure Choices LLC may remove a participant from group sessions for safety reasons, disruptive behavior, threats, harassment, or other conduct that prevents a productive learning environment. I acknowledge that I have read, understood, and agree to the terms above. I consent to participate in Secure Choices LLC services and understand my responsibilities regarding attendance, conduct, confidentiality, and court communication where applicable.
Telehealth services informed consent Part 3 of 6
Telehealth services informed consent For virtual, hybrid, phone, messaging, and digital service delivery
Required if you chose virtual or hybrid. Optional for in person.
Telehealth involves electronic communication that allows Secure Choices LLC to deliver services when the client and provider are not physically in the same location. This may include video conferencing, phone calls, secure messaging, email, and other digital technologies.
Consent and signature By signing below, I consent to receive telehealth services from Secure Choices LLC. I understand that I may withdraw this consent in writing at any time.
Insurance and payment authorization Part 4 of 6
Insurance and payment authorization Billing information and client payment responsibility
Sign this section if you are using insurance. Your name, date of birth, phone and address are copied from the first section.
I authorize Secure Choices LLC to bill my insurance company for covered services. I understand that I am responsible for any charges, copays, deductibles, or balances not covered by my insurance plan unless otherwise agreed in writing.
Consent and signature I certify that the information provided is correct. This authorization allows Secure Choices LLC to release necessary information to my insurance company or payer for billing and claims processing. This authorization remains in effect until revoked in writing.
12-week anger management pre-test Part 5 of 6
12-week anger management pre-test Complete before beginning the program
Choose the best answer for each question. This pre-test helps Secure Choices LLC understand your starting knowledge and does not prevent enrollment.
Pricing and completion acknowledgment Part 6 of 6
Pricing and completion acknowledgment Payment options and completion requirements
Materials and certificate are included when the participant meets completion requirements. Payment plans may be approved by Secure Choices LLC. Missed sessions, cancellations, or failure to complete assignments may affect completion status and any reports sent to court, probation, parole, or referring parties.
