AGREEMENT FOR DBT SKILLS TRAINING

Welcome to Daily DBT - we look forward to working with you. This document contains important information about our services and business policies. Please feel free to ask us questions about this information.

PSYCHOLOGICAL SERVICES

You are entering a Skills Training Group using a model of therapy called Dialectical Behavior Therapy (DBT This therapy was originally developed to help individuals with dysregulation problems, which can include problems with regulating emotions, behaviors, thoughts, relationships, and sense of self. Research shows DBT is effective in reducing a wide range of problematic symptoms and we look forward to helping you learn skills to make positive changes in your life.

MEETINGS

• Prior to the first meeting, we will conduct an initial assessment to help determine whether you are a good match for the group and vice versa. Our recommendations for group and/or other therapy services will be discussed at that time or after consultation with the Daily DBT team.
• Groups are typically held weekly for the full module and last 90 minutes for adults and adolescents; 60 minutes for middle school students.
• Daily DBT teaches content in the form of "modules," that typically last anywhere from 12 to 18 weeks on average. Information about the specific module you will join and number of classes will be relayed during phone and in-person screenings. Details about modules and content are on the Daily DBT website. If you choose to do the full program consisting of all modules, it will last approximately one year, including breaks between each module and for holidays.
• You will be notified of key dates for each module (i.e., first and last groups and any anticipated weeks off Daily DBT reserves the right to change meeting times as necessary, but will give as much notice as possible in this event.

GROUP REQUIREMENTS

• Consistent attendance. If you miss more than 3 group sessions in a module, you may be asked to leave group (you are still responsible for payment of the full module in this event Group leaders will discuss recommendations for either returning to group or utilizing other services.
• Individual therapy. All group members (with the exception of middle school students) are required to be engaged in consistent individual therapy while enrolled in group. If you are not attending individual therapy you may be asked to leave group or pause group while you determine the best course for individual therapy.

PROFESSIONAL FEES

The fee for the initial evaluation (aka: Group Screening) is $325 for adults and $350 for adolescents. Weekly groups are $110 for adults and $115 for adolescents. If you choose to utilize any individual skills training, those session are charged at the individual therapy rate for the therapist you choose to work with. We will discuss this rate prior to the start of services. Fees typically increase each year. Please note that these fees also apply to phone calls or other clinical time (i.e., providing documentation that you request If you become involved in legal proceedings that require our participation, you will be expected to pay for all professional time at an hourly rate of $350, including preparation and transportation costs, even if we are called to testify by another party.

DBT Groups are charged similarly to tuition for a class. You are expected to pay for all sessions in the module you commit to, regardless of attendance. Additionally, you agree to be financially responsible for the entire module regardless of your completion of the module. For example, if you decide to leave group (or are asked to leave group) prior to the end of the module you will be charged for all missed sessions until the previously planned end date for that module.

BILLING AND PAYMENT

Payment is due at the time of service, unless otherwise agreed upon, and we require a credit card be kept on file for billing. We use the Square App to process debit and credit card payments. Daily DBT is out-of-network for all insurance plans. At the end of each month, we will provide you with a statement of your transactions for that month which contains all of the information necessary for you to file a claim with your insurance company for out-of- network reimbursement, if you choose to do SO. You should be aware that your contract with your health insurance company requires that your therapist provide a clinical diagnosis.

GOOD FAITH ESTIMATE

You have the right to receive a "Good Faith Estimate" (GFE) explaining how much your medical care is anticipated to cost. Under the law, health care providers will give patients who do not have insurance or who are choosing to not use insurance an estimate of the bill for services. You may request a Good Faith Estimate for the total expected cost of any non-emergency services. If you would like to receive a GFE, please let your therapist know and this will be provided to you in writing at least one day before your scheduled service and placed in your clinical file. If you receive a bill that is at least $400 more than your GFE, you can dispute the bill. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

CONTACT

You may contact Daily DBT by phone or email at any time. However, voicemail and email are only checked and responded to during typical business hours. We will make every effort to return your call as soon as possible. If you experience an emergency, contact your individual therapist and follow through with any crisis coping plan developed with that person. You can also call the GA Crisis and Access line 24 hours a day at 1.800.715.4225. If you believe you cannot maintain your own safety and life, or it is a medical emergency, call 911 or go to a hospital emergency room. Please notify us if any psychiatric emergency or crisis services have been utilized as soon as possible.

You may also email or text regarding scheduling only. Please be aware that emails and texts will only be viewed/read Monday through Friday 8am to 5pm and may not be used to address crises, communicate information related to personal and/or clinical issues, or to obtain treatment in any form. Information provided through electronic transmission, other than that pertaining to scheduling, will be placed into your clinical file and becomes a part of your confidential record. This type of communication should not be considered a secure form and the confidentiality of an electronic message cannot be guaranteed.

TERMINATION OF SERVICES

Clinical services may be terminated under the following conditions: 

• We agree that your treatment goals have been accomplished and there is no need for continued treatment. 
• You wish to discontinue services for any reason (although if you are enrolled in a module you will be responsible for paying the remainder of that module 
• We believe another mental health provider or type of treatment would be more appropriate or that progress toward treatment goals has ceased. In this case, we will discuss relevant issues and come to a joint decision regarding termination of treatment. 
• You do not adhere to treatment structure or group guidelines or do not follow through with essential recommendations made during treatment. 
• You miss more than three group sessions within any one module. 
• You do not communicate intent to continue with the subsequent module within the specified time frame after being contacted by Daily DBT. 
• You fail to remit payment in full by the completion of the module.

If you choose to terminate group prior to the completion of a module, your group leaders will communicate this to your individual therapist.

LIMITS OF CONFIDENTIALITY

The law protects the privacy of all communications between a client and a psychologist. This means that everything discussed in therapy is confidential and private, with the exceptions listed below. We can only release information about your treatment to others if you sign a written Release Form. 

Your therapist is required to disclose information without your consent in the following situations:

• If there is reason to believe that a child, disabled adult, or elderly person (over 65 years old) is currently being abused, neglected or exploited. We are required to report to the appropriate governmental agency. 
• If there is reason to believe that a client presents a serious danger of violence to him/herself or to another person, we are required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client. 

If any of these situations arise, we will make every effort to fully discuss with you before taking any action and we will limit our disclosure to what is necessary.

Please be aware that confidentiality between group members is NOT protected by the law. We ask that all group members commit to maintaining the privacy and confidentiality of other members in their group by not discussing any identifying information outside of group. Any group member who violates the confidentiality of another group member will be asked to leave group. By signing this agreement, you acknowledge that we cannot guarantee confidentiality by other group members and you assume that risk by participating in group.

Daily DBT is a group practice. Please note that therapists working for Daily DBT have access to information included in all files - this information will only be accessed for purposes of maintaining business and ethical standards. As a group we may discuss therapy cases for purposes of clinical consultation only.

FOR MINORS AND PARENTS ONLY

Clients under 18 years old and their parents/guardians should be aware that the law allows parents/guardians to examine their child's treatment records unless the therapist believes that doing so would harm the child. Because privacy in therapy is often crucial to successful progress, particularly with children and teenagers, signatures below serve as agreement that you will give your child a degree of privacy in the relationship with his/her therapist and that you understand you will not be provided with specific details of what is discussed in therapy.

As an alternate to full treatment record access, we will provide parents/guardians with general information about the progress of the child's treatment and attendance at scheduled sessions. If requested, we are happy to provide parents/guardians with a summary of their child's treatment when it is complete. During treatment, parents will be informed of any serious health or safety issues regarding likely risk to your child, with the understanding that the determination of risk will be made by the therapist. Before giving parents/guardians any information, we make every effort to first discuss the matter with the child and do our best to handle any objections he/she may have.

Parents/guardians are not required to remain on site for the length of the group meetings; however all group members must be provided with punctual transportation at the end of the scheduled group meeting time.

ADDITIONAL FORMS PROVIDED TO YOU

Your signature on this form also indicates that you have been provided with, read, and agree to the terms outlined in the Georgia Notice form. If you like an additional paper copy of this consent form then please let us know and one will be provided to you.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS DOCUMENT AND AGREE TO ITS TERMS.