DBT Therapy Agreement

Thank you for choosing Northland Counseling Center, Inc. Dialectical Behavior Therapy (DBT) program. Northland offers you certified DBT services!

Please review, sign and date the form below. This form is an agreement between you and your therapist. This form explains what you agree to while you are participating in the DBT program. If you have questions, please ask your DBT Therapist or group facilitator.

DBT Contract

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DBT Contract

Client Agreement

Please Review and check the box below to indicate you have read the following information. Please sign your name and date the form below:

By checking this box, I have read and understand the following information; if you have questions please ask your DBT Therapist. Please sign form below.

* I agree to work on decreasing suicidal behaviors and thoughts.

* I agree to work on decreasing self-harmful behaviors and thoughts.

* I agree to attend all scheduled individual therapy sessions. If I am sick or in an emergency I will call to cancel my appointment. Missing two therapy appointments may prompt review by the individual therapist and/or DBT Consultation Team and may require renegotiating for a new treatment contract and/or a vacation from treatment. Missing four consecutive individual DBT sessions will prompt termination from the DBT treatment program. Clients are eligible to reapply for admission to the DBT treatment program 3 months following termination with readmission to be determined by the individual therapist and DBT consultation team.

* I agree to work on any therapy-interfering behaviors (examples: not being attentive, not collaborating with the therapist, noncompliance with treatment) and to talk about my therapist’s therapy-interfering behaviors (examples: taking extreme positions, being disrespectful).

* I agree to work on building a more worthwhile life.

* I agree to attend and participate in the Skills Training Group. Missing four consecutive sessions for any reason will result in termination from the DBT program. Client may apply for readmission to the DBT treatment program after a minimum of 3 months has lapsed following termination. Readmission will be determined via consultation with the individual therapist and the NCC DBT consultation team.

* I understand that my therapist and skills trainers will be discussing my progress in consultation and professional supervision.

* I consent to tape-recording my therapy and skills training sessions for purposes of my review, and to facilitate clinical supervision with verbal notification and written consent at the time of tape-recording (may or may not apply).

* I agree to abide by any data collection conditions approved by Northland Counseling Center.

** We will work together for 12 months. At the end of that time, we will evaluate progress on goals. If there is evidence that our work together is effective, we may renew our contract for another specified period of time.

DBT Contract

Therapist Agreement