This Informed Consent for Dialectical Behavior Therapy (DBT) group contains important information about this form of treatment. Please read this carefully, and let your professional know if you have any questions.
When you sign this document, it will represent an agreement between you, your professional, and Assessment and Therapy Associates of Grand Forks (ATAGF). This document is intended to supplement the Patient Services Agreement you signed to participate in individual therapy and does not replace any terms set forth in that agreement.
YOUR PROFESSIONAL
Your DBT group therapist will be Nicole Franklin, MSW, LCSW, who is a Licensed Clinical Social Worker. She has a Masters of Social Work and completed the requirements for licensure as a social worker in North Dakota (#5649). She also has specialized training in DBT and is required to complete continuing education credits in social work to maintain her license.
PSYCHOLOGICAL SERVICES
Your adolescent is coming to ATAGF for a Dialectical Behavior Therapy (DBT) group, which is a type of group therapy that works by teaching clients skills to cope more effectively with emotions, manage challenging behaviors, and improve relationship effectiveness. DBT groups are strongly supported by research. This group with address topics including, but not limited to, healthy relationships with people, healthy relationships with food, having a healthy body image, and using DBT skills to manage stress and/or trauma.
Therapy groups in general are not easily described in general statements. They vary depending on the personalities of the professional and patient and the problems your adolescent is experiencing. For the DBT group to be most successful, your adolescent will have to work on things discussed during DBT group both during group sessions and at home. It is not like a medical doctor visit. Instead, it calls for a very active effort on your adolescent’s part.
Sessions will be done in a group format, and all patients participating in this group will be adolescents. During the initial session, a set of group rules will be created by Ms. Franklin and the participants, and all group participants agree to follow these rules. Ms. Franklin is bound by law to maintain confidentiality. She also may have students in medicine (medical students, medical residents) or mental health (psychology, social work, counseling) professional fields observing group therapy sessions who are also bound by law to maintain confidentiality. If your adolescent participates in this DBT group, your adolescent and all other group members agree to protect the confidentiality of other group members. A group member will be asked to leave the DBT group if they are unable to maintain confidentiality.
DBT groups can have benefits and risks. Common benefits of DBT groups are managing emotions more effectively, improved relationships, and improved self-image. Results of DBT groups are often maintained over time. Although DBT groups are generally effective in managing emotional and relationship concerns, they do not always work right away. It can take time for your adolescent to learn and practice skills learned in treatment. For the DBT group to be effective, it is important that your adolescent is open to confronting unhelpful thoughts and behaviors. While risks to the DBT group are likely to be mild, it may be uncomfortable for your adolescent at times, especially when discussing painful experiences,
thoughts, and feelings. Working with a professional trained in offering DBT groups can help minimize risks of this treatment because they are trained to offer support and tools to cope with temporary challenges or setbacks.
Alternatives to DBT groups include individual therapy or psychotropic medication, and your professional can provide referrals for these alternatives, if desired.
You should evaluate this information about the DBT group along with your own opinions of whether you feel comfortable with your adolescent working with Ms. Franklin in this group. DBT groups involve a commitment of time, money, and energy, so you should be very careful about the professional you select for your adolescent. If you have questions about our procedures at ATAGF, you should discuss them with your professional whenever they arise. If your doubts persist, your professional will be happy to help you set up a meeting with another mental health professional for a second opinion.
MEETINGS
Prior to joining the DBT group, Ms. Franklin will meet with your adolescent to determine if the group is appropriate for them. If it is not the right treatment for your adolescent, Ms. Franklin will discuss other services that may be helpful.
If your adolescent begins the DBT group, it is generally 60-minute sessions held every week or every other week, although some sessions may be shorter/longer or more/less frequent. These sessions will be held in person (at 907 Lincoln Avenue, Harvey, ND) or via telehealth. If your adolescent attends the group via telehealth, you must also sign ATAGF’s Telehealth Informed Consent. The length of a course of a DBT group varies based upon goals your adolescent establishes with Ms. Franklin, your adolescent’s symptoms, their severity, frequency of sessions, your adolescent’s motivation to participate in a DBT group, and your adolescent’s ability to implement learned skills outside of session.
Once the group sessions are scheduled, you are asked to provide 24 hours [1 day] advance notice of cancellation if your adolescent is unable to make it to a group session. Although ATAGF provides reminder calls or SMS (text) messages for appointment times as a courtesy, it is your and your adolescent’s responsibility to know when DBT group meetings are held. Given reminder calls or SMS (text) messages can be made less than 24 hours in advance, if you or your adolescent cancels when a reminder is received, it is likely that your cancellation will be considered a late cancellation/no-show. After two late cancellations and/or no-shows, ATAGF professionals reserve the right to remove your adolescent from the DBT group and speak with you and/or your adolescent prior to them joining the DBT group again to determine your adolescent’s commitment to the group.
FEES, BILLING, & PAYMENTS
The fee for the DBT group sessions is $100 per group session. You will be expected to pay for each session at the time it is held unless you have insurance coverage (insurance will be billed for DBT group sessions if patients have insurance coverage) or make alternative arrangements with Ms. Franklin. If you have insurance coverage, your insurance will be billed, and you are responsible for any outstanding balance after insurance has paid (e.g., deductible, copays). For additional information about fees, billing, and payments, please refer to the Patient Services Agreement you signed when your adolescent initiated individual therapy.
PROFESSIONAL RECORDS & RECORDINGS
The DBT group sessions shall not be recorded in any way by any party unless agreed to in writing by mutual consent (parents/guardians of all group members and Ms. Franklin). Ms. Franklin will maintain a record of DBT group sessions in the same way they maintain records of in-person and/or telehealth individual sessions in accordance with ATAGF policies.
INFORMED CONSENT
This agreement is intended as a supplement to the general informed consent that you agreed to at the outset of your adolescent’s work with your professional and does not amend any of the terms of that agreement. If you are unable to agree to or abide by these terms, your professional may elect to terminate DBT group services with your adolescent and refer your adolescent to other services that may be beneficial for them.
By signing the document below, you are stating that you are aware that your professional may contact necessary authorities in case of an emergency with your adolescent. You are also acknowledging that if you believe there is imminent harm to your adolescent or another person that you will seek care for your adolescent immediately through your own local health care provider, at the nearest hospital emergency department, or by calling 911.
MINORS & GUARDIANS
Patients under 18 years of age who are not emancipated, and their guardians, should be aware the law may allow guardians to examine their adolescent’s treatment records unless your professional decides that such access is likely to injure the adolescent or the legal guardian and the adolescent’s professional agree otherwise. Because privacy in psychotherapy, including DBT group therapy, is often crucial to successful progress, particularly with adolescents, it is sometimes ATAGF’s policy to request an agreement from guardians that they consent to give up their access to the adolescent’s records. If they agree, during treatment, the professional will provide them only with general information about the progress of the adolescent’s treatment, and their attendance at scheduled sessions. The professional may also provide guardians with a summary of their adolescent’s treatment when it is complete. Any other communication will require the adolescent’s Authorization, unless the professional feels the adolescent is in danger or is a danger to someone else, in which case, the professional will notify the guardians of their concern. Before giving guardians any information, the professional will discuss the matter with the adolescent, if possible, and do their best to handle any objections the adolescent may have.
SIGNING THIS AGREEMENT
By signing this Agreement, you acknowledge, as a parent/legal guardian of the adolescent client, that you accept responsibility and acknowledge the risks of confidentiality with DBT group session. You understand that this Agreement is intended to supplement (not amend or replace) the existing general informed consent that you agreed to at the outset of your adolescent’s work with your professional.
You have read this document and had the opportunity to ask questions. You discussed this with your adolescent’s professional and understand the risks/limitations and benefits to DBT group therapy with your adolescent. You agree to your adolescent participating in DBT group sessions with Ms. Franklin.
Your typed name and/or signature below indicates agreement with the terms and conditions presented in this document (in addition to the terms and conditions presented in the Patient Services Agreement signed at the outset of your and your adolescent’s relationship with ATAGF). By typing your name or signing electronically, you are effecting all the force of your legal, handwritten signature.