Dialectical Behavior Therapy (DBT) Skills Group Agreement

Thank you for your interest in DBT Skills Group at Central Minnesota Mental Health Center (CMMHC Understanding these guidelines is necessary to succeed in group. Please review and sign the following document before starting DBT Skills Group.

• I understand my diagnosis and that my symptoms can be addressed by DBT Skills Group, which covers mindfulness, distress tolerance/crisis management, interpersonal effectiveness/relationships, and emotion regulation skills.
• While I am in DBT group, I understand that I am required to attend individual therapy as recommended by my therapist. I can see any therapist of my choice.
• If I see an individual therapist who is outside of CMMHC, I have signed a Release of Information form so my DBT skills group leader(s) can coordinate about missed groups and concerns for follow-up in individual therapy.
• A Comprehensive Evaluation and therapy consent forms have been completed at CMMHC.
• I understand that therapy consent forms must be updated yearly, even if I have a therapist outside CMMHC.
• I understand that the minimum time commitment for DBT group is six months (26 weeks). I have the option to complete all modules twice (52 weeks I understand that weekly attendance is required. I will schedule other events outside of group time.
• I understand that I must attend the first two weeks of group (orientation and mindfulness).
• I understand that if I miss one of these first two groups, I will be removed from the group and might be able to restart at the next mindfulness module 8-9 weeks in the future, if space allows.
• I understand that missing three sessions within one 8–9-week module results in removal from group, regardless of why I missed group. To rejoin, I understand that I need to be re-referred to the DBT program, and I will have to wait a minimum of 26 weeks until the missed module restarts, if space allows. I understand that letters are sent for each missed group so I can track how many groups I have missed. I agree to notify my group leader if I need to miss group.
• If I no-show a group, I understand that my individual therapist will be contacted so they can review why I missed group and help me find solutions, if needed.

• I agree to complete a DBT diary card weekly. Diary cards can be found on DBTSelfHelp.com; in the DBT binders; or attached to the weekly DBT e-mail.
• I agree to complete the PHQ-9 depression screening weekly. I can find it attached to and/or embedded into the weekly DBT e-mail.
• If I am late, I understand that I will be allowed in group after the opening mindfulness activity is completed, about 5-15 minutes after the start of the group.
• I agree to avoid disclosing the details of triggering experiences (self-harm, drug use, etc at DBT skills group. I agree to only review these details in individual therapy.
• I understand that the focus of the group is to learn and practice DBT skills, and that I am not able to process my emotions and past experiences in group.
• I agree to limit relationships with other group members outside of the group and to notify the group leader immediately if I know someone in the group. If needed, my group leader will try to transfer me to another group.
• I agree to work with my individual therapist to develop a safety and crisis plan. I understand that a crisis cannot be effectively addressed in group.
• I agree to preserve the privacy of all group members. For virtual groups, I agree to meet in a private space where I will not be overheard by other people (including children I will not record or take a screenshot or picture during virtual group meetings.
• I understand that this checklist will be sent to my individual therapist or other referral source to review with me.
• After signing, I will return this checklist to CMMHC via: e-mail to care@cmmhc.org; mail to CMMHC at 253 8th St. NW, Suite A, Elk River, MN 55330; fax to (763) 441-9057, Attention: DBT Intake; or drop it off in person at any CMMHC clinic.