DBT Group: Registration, Disclosure and Informed Consent

DBT Group: Registration, Disclosure and Informed Consent

Complete your participant information, review the disclosure and informed consent, acknowledge the terms, e-sign, and submit payment to reserve your spot.
DBT Group: Art of Mindfulness. Facilitator: Tatum Mackay, Licensed Mental Health Counselor Associate. Wednesdays at 5 pm, in person and online. Starts November 4, 2026. 8 weekly sessions of 90 minutes. $70 per session; $560 for all 8 sessions, paid at registration. Please read each section, complete your information, sign, and pay to reserve your spot.
Participant Information
Full legal name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Mobile phone
Please enter a valid phone number.Format: (000) 000-0000.
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How will you attend?
Emergency contact name

First NameLast Name
Emergency contact relationship
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Practice: Wellness Counseling Inc., 755 Winslow Way E, Suite 303, Bainbridge Island, WA 98110. Phone: (360) 207-1588. Facilitator: Tatum Mackay, Licensed Mental Health Counselor Associate (LMHCA). Supervision: As a Licensed Mental Health Counselor Associate, Tatum provides services under the supervision of an approved supervisor, [Heather Beirman MA, LMHC]. Associates do not independently provide mental health counseling for a fee; group fees are paid to Wellness Counseling Inc.

Methods and orientation: This group teaches Dialectical Behavior Therapy (DBT) skills, an evidence-based approach that combines cognitive-behavioral techniques with mindfulness strategies, through four modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. Course of treatment: 8 weekly group sessions, Wednesdays at 5 pm, beginning November 4, 2026. Each session lasts 90 minutes. Billing: The cost is $70 per session. The full series of 8 sessions ($560) is paid in advance at registration. Cancellation and Refund Policy Refunds are based on how far in advance you cancel before the first group session: - 30 or more days before: 75% refund ($420) - 14 to 29 days before: 50% refund ($280) - 7 to 13 days before: 25% refund ($140) - Less than 7 days before: no refund No refunds are given after the group begins. Missed sessions are not refunded or made up, but you may attend online that week. If Wellness Counseling Inc. cancels a session, it will be rescheduled. If the group does not run, you may choose credit toward a future group or a refund. If your facilitator recommends you stop attending for clinical reasons, unused sessions will be credited or refunded. Group therapy may not be covered by insurance; Wellness Counseling Inc. can provide a receipt on request. Your rights: You may refuse treatment at any time and you may choose a practitioner and treatment approach that best suits your needs. This disclosure does not create new rights for you, and it does not change any state or federal law, regulation, or professional standard.

Complaints: Contact Arilda Surridge, Director of Wellness Counseling Inc., at asurridge@wellnesscounselinginc.com.
Group Therapy Informed Consent
About the group: This is a structured DBT skills group. It is not a crisis service and is not a substitute for individual mental health treatment. Participation is voluntary, and you may stop at any time. Benefits and risks: Group therapy can build coping skills, self-awareness, and connection. Learning and practicing DBT skills may bring up uncomfortable feelings or memories; you may pause or step back from any activity at any time. Group confidentiality: Members agree to keep the names, identities, and anything shared by other members private, both during and after the group. The facilitator protects your information, but cannot guarantee that every group member will keep information confidential. Limits of confidentiality: Under Washington law, the facilitator may need to share information without your consent to protect someone from harm, including suspected abuse or neglect of a child or vulnerable adult, a serious threat to your own safety or the safety of others, or when required by a court order or law. Records: Wellness Counseling Inc. keeps records of your participation and protects your health information under HIPAA and Washington's Uniform Health Care Information Act (RCW 70.02). Online sessions: If you attend online, you agree to join from a private place, to be physically located in Washington State during each session, and to have a working phone available. Online services carry some risk of technical failure or privacy breach. No group member may record any session. Emergencies: If you are in crisis between sessions, call or text 988, call 911, or go to the nearest emergency room.
Acknowledgments
Signature
I have received, read, and understood the Disclosure Statement above, and I may keep a copy.
I agree to keep the identities of other group members and what they share confidential.
I understand the limits of confidentiality described above.
I understand that this group is not a crisis service, and I know how to get emergency help.
If I attend online, I will be physically located in Washington State and in a private place during each session.
I understand the fees, the advance payment of $560 for 8 sessions, and the Cancellation and Refund Policy.
I am 18 years of age or older.
Participant signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your facilitator will also sign and date this disclosure and consent, and a copy will be sent to you.
Payment

DBT Group – 8 sessions (Wednesdays, starting Nov 4, 2026)

DBT Group 8 Sessions

$560.00 Quantity

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

DBT Group: Registration, Disclosure and Informed Consent

Participant Information

Group Therapy Informed Consent

Acknowledgments

Signature

Payment

DBT Group – 8 sessions (Wednesdays, starting Nov 4, 2026)*

DBT Group – 8 sessions (Wednesdays, starting Nov 4, 2026)