Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Policy and Disclosure Statement – Agreement for Services Introduction This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask your therapist/DBT Skills Trainer any questions that you may have regarding its contents.

Information about Your DBT Skills Trainer At an appropriate time, your DBT Skills Trainer and Co-Facilitator will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your DBT Skills Trainer’s background, experience and professional orientation.

Licensure status _X__ Licensed Marriage and Family Therapist

Information about This Practice The name of this practice is: Silicon Valley Executive Counseling (formerly CriticalPath Counseling) Marriage & Family Therapy, A Professional Corporation The individual therapist who operates this practice is: MELINDA CARLISLE BRACKETT (Name of Therapist )

MFC (License Type)

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43877 (License Number)

Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Psychotherapist-Patient Privilege The information disclosed by Patient, as well as any records created, is subject to the psychotherapistpatient privilege. The psychotherapist-Patient privilege results from the special relationship between the Therapist/DBT Skills Trainer and Patient in the eyes of the law. It is akin to the attorney-client privilege or doctor-patient privilege. If therapist/DBT Skills Trainer received a subpoena for records, disposition testimony, or testimony in a court of law, Therapist/DBT Skills Trainer will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapistpatient privilege with his/her attorney.

FEES and INSURANCE The fee for service is $___185.00____________ per individual therapy session or DBT skills group intake session. The fee for service is $____$75___________ per group therapy session Individual Sessions and intake sessions are approximately 50 minutes in length and group sessions are 90 minutes in length. Fees are payable at the time that services are rendered.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Please inform your therapist/DBT Skills Trainer if you wish to receive a receipt that you may utilize for health insurance reimbursement. Although your therapist/DBT Skills Trainer is happy to assist your efforts to seek insurance reimbursement by providing statements, we are unable to guarantee whether your insurance will provide payment for the services provided to you. Please discuss any questions or concerns that you may have about this with your therapist or skills trainer. Fees for group sessions are payable at the beginning of each DBT Skills Training Module. The cost for each DBT Skills Training Module is $450 for 6 week modules and $600 for 8 week modules. Cash, check or credit cards are accepted. Should you miss a session for any reason, even if it is a planned absence, no refunds will be given for the missed sessions. Every effort should be made to attend all sessions to gain the maximum benefit.

Therapist Communications Your DBT Skills Trainer or co-facilitator may need to communicate with you by telephone, mail or other means to discuss schedule changes or updates. Please indicate your preference by checking one of the choices below. Please be sure to inform your Skills Trainers if you do not wish to be contacted at a particular time or place, or by a particular means. _____My skills trainers may call me at my home. My home number is: (

) ______________________

_____My skills trainers may call me on my cell phone. My cell number is: ( _____My therapist may call me at work. My work phone number is: (

)____________________

)________________________

_____My therapist may send mail to me at my home address: ____________________________________________________________________________________ _____My therapist may communicate with me by email. My email address is: ____________________________________________________________________________________ _____My therapist may send a fax to me. My fax number is: (

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)______________________________

Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Confidentiality All communications between you and your therapist/DBT Skills Trainers will be held in strict confidence unless you provide written permission to release information about your treatment. There are exceptions to confidentiality. For example, therapists/DBT Skills Trainers are required to report instances of suspected child or elder abuse. Therapists/DBT Skills Trainers may be required to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the patient that the FBI sought or obtained the items under the Act.

Patient Litigation Our primary role is to offer you Dialectical Behavior Therapy Skills Training services. Our focus will be on your learning and understanding of the course concepts. If you are planning to use the information collected in DBT Skills Training sessions for legal proceedings of any kind, we want you know that our ongoing notes are kept to a minimum and are limited generally to only attendance. Therapist/DBT Skills Trainers will not voluntarily participate in any litigation, or custody dispute in which patient and another individual, or entity, are parties. Therapist/DBT Skills Trainer have a policy of not communicating with patient’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in patient’s legal matter. Therapist/DBT Skills Trainers will generally not provide records or testimony unless compelled to do so. Should therapist/DBT Skills Trainers be subpoenaed, or ordered by a court of law, to appear as a witnesses in an action involving Patient, Patient agrees to reimburse Therapist/DBT Skills Trainer for any time spent for preparation, travel, or other time in which Therapist/DBT Skills Trainer has made him/herself available for such an appearance at Therapist/DBT Skills Trainer’s usual and customary hourly rate. Your signature indicates that you have read this agreement for services carefully and understand it contents. Please ask your DBT Skills Trainer to address any questions or concerns that you have about this information before you sign!

____________________________________________________________________________________ Name of Patient Signature of Patient Date

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Client Information Name _______________________________________________Date of Birth_____________________ Address _____________________________________________________________________________ Email_______________________________________________________________________________ Phone#______________________________________________Alt.#____________________________ Is it OK to leave messages:

At home: Yes/No

At work: Yes/No

On cell phone: Yes/No

Spouse Name ________________________________________Contact# ________________________ Person who will be responsible for payments _______________________________________________ Emergency Contact Information Name _______________________________________________ Relationship ____________________ Phone # ______________________________________________/______________________________ Name _______________________________________________ Relationship ____________________ Phone # ______________________________________________/______________________________ Personal Information Children’s names & ages: ____________________________________________________________________________________ ____________________________________________________________________________________ Highest grade/degree: _________________ Major: ______________ Studying now? _______________ Employer/Occupation: _________________________________________________________________

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

PERSONAL HISTORY Have you ever been in counseling, DBT Skills Training or therapy before? ________________________ If yes, explain briefly the focus of treatment: ____________________________________________________________________________________ ____________________________________________________________________________________ Have you ever been hospitalized? If so, what for and # of times? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ What is your reason for seeking counseling or skills training? ____________________________________________________________________________________ ____________________________________________________________________________________ What are your goals for counseling or skills training? ____________________________________________________________________________________ ____________________________________________________________________________________ Referring physician name/ phone number/address: ____________________________________________________________________________________ ____________________________________________________________________________________ Are you on any type of prescribed medication? If so, what type and why? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have you ever attempted suicide? _______________________________________________________ When? _____________________________________________________________________________ ____________________________________________________________________________________ Describe the circumstances that led to the attempt? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Are you currently having suicidal thoughts? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Please describe your childhood: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Were you ever subjected to verbal, physical, emotional, sexual abuse? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have you been a victim of a violent crime? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Do you engage in self-harm behaviors like cutting or other self-injury? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

MEDICAL HISTORY Have you ever been diagnosed with a serious illness? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ Do you have any medical conditions that may affect your mental treatment? ____________________________________________________________________________________ ____________________________________________________________________________________ Please describe your overall health: ____________________________________________________________________________________ ____________________________________________________________________________________ Are you physically active? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ Are you experiencing any medical/physical symptoms that attribute to a mental, emotional, or stressrelated condition? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 7

Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Have you ever been in a 12-step program? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Do you smoke? Yes/No

How much? ___________________ For how long? ________________

Do you drink alcohol? Yes/No On average, how much do you drink in a week? ____________________________________________________________________________________ ____________________________________________________________________________________ Do you currently use illegal drugs? Yes/No Please describe your drug of choice: ____________________________________________________________________________________ ____________________________________________________________________________________ Have you ever used illegal drugs or abused prescription drugs? Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________

FAMILY OF ORIGIN HISTORY Mother’s name, age, living/deceased, client’s age at time of mother’s death, description of relationship with mother: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Father’s name, age, living/deceased, patient’s age at time of mother’s death, description of relationship with mother: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Names and ages of siblings: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

OTHER INFORMATION Please describe your spiritual orientation if any: ____________________________________________________________________________________ ____________________________________________________________________________________ Are you now or have you been involved in a lawsuit? ________________________________________ Please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ Please feel free to include any other information, not previously requested; that you believe is relevant to your treatment: ____________________________________________________________________________________ ____________________________________________________________________________________

Treating Doctors & Therapists Physician Name(s), address(es), phone number(s) ____________________________________________________________________________________ ____________________________________________________________________________________ Psychiatrist(s) Name(s), address(es), phone number(s) ____________________________________________________________________________________ ____________________________________________________________________________________ Therapist(s) Name(s), address(es), phone number(s) ____________________________________________________________________________________ ____________________________________________________________________________________

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

CHECK ITEMS THAT APPLY TO THE WAY YOU FEEL OR BEHAVE: __ headaches

__ nightmares

__ can’t stay asleep

__ dizziness

__ sexual problems

__ ready to explode

__ stomach problems

__ financial problems

__ unable to work/study

__ bowel problems

__ depressed

__ can’t get interested

__ feel tense

__ panicky feelings

__ can’t have a good time

__ irritable

__ bulimia/anorexia

__ trouble concentrating

__ unusual thoughts

__ always worried

__ can’t make/keep friends

__ strange experiences

__ unable to relax

__ fear loss of self-control

__ weight change

__ feel worthless

__ feel apart from family

__ always tired

__ can’t make decisions

__ fear things I shouldn’t

__ can’t go to sleep

__ thoughts of suicide

__ conflict within family

__ racing thoughts

__ like high-risk situations

__ don’t need a lot of sleep

__ restrict food intake

__ binge/purge

__ number times per day/week

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Payment by Credit Card (Optional) You have the option of storing a credit card in our system that can be used after each session. This is a convenience we offer if you would rather not have to remember to bring payment each time you have an appointment. You will need to fill out the Credit Card Authorization Form at the end of this packet. Insurance Information While we are not a part of any insurance panel, you may still be able to collect reimbursement for your visits from your insurance company. We do not send these forms to your Insurance Company, but provide the form to you so that you can submit the form and be reimbursed directly from Insurance, if they are going to cover any portion of your visit. Do you have Insurance?

Yes / No

If No, would you still like to receive a form each month detailing your visits for personal records? Yes / No Please fill out the following information: Name of person Insured __________________________________Relationship___________________ Address _____________________________________________________________________________ Date of Birth:_________________________________________________________________________ Marital Status __________________________________________ Employed?____________________ Employers Name: _____________________________________________________________________ Name of Insurance Co _________________________________________________________________ Insurance Group # _______________________________________ID#__________________________ Drivers License _______________________________________________________________________

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

TREATMENT AGREEMENT

I, __________________________________ agree that my participation in Melinda Carlisle Brackett’s Dialectical Behavior Therapy Skills Training Class is with the following understandings: 1. I understand that my skills trainer is Melinda Carlisle, Licensed Marriage and Family Therapist, #43877. 2. I understand that although there is empirical evidence for the effectiveness of Dialectical Behavior Therapy, this evidence is not presented as a guarantee either direct or implicit of the efficacy of this treatment. 3. I understand that Dialectical Behavior Therapy may not be the “standard of care” for any particular clinical population, and that each individual must independently evaluate and use his or her own judgment in choosing among treatments available. 4. I understand that there are other treatments available for individuals who present with suicidal, para-suicidal (other self-harm) and impulsive behaviors and that Dialectical Behavior Therapy is only one such treatment. 5. I understand that if I am not regularly participating in individual DBT psychotherapy with an intensively trained DBT therapist who participates on a consultation and adheres to the standard treatment protocol, then I may not be getting the full benefit of the skills training. 6. I understand that my DBT skills trainers and DBT Therapist will be in communication with one another regarding my participation in Skills Training group as is customary on Dialectical Behavior Therapy Consultation Teams. I understand that this communication will consist of progress reports, attendance reports, and other treatment coordination for my benefit. Only first names will be used. I understand that consultation between my skills trainers and my therapist will end when I am no longer participating in DBT Skills training. . By signing my name below, I understand and accept all terms of this agreement. ____________________________________________________________________________________ Client signature Print Name Date ____________________________________________________________________________________ DBT Skills Trainer/Therapist Signature Print Name Date

AUTHORIZATION TO EXCHANGE INFORMATION

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

A.

By signing this form, I (client’s full name) _____________________________________authorize the use, disclosure, and exchange of my individually identifiable health information between the following parties: Current Therapist, Psychiatrist, Emergency Contact Name (Please list all that apply): Name: ____________________________________ Telephone number Name: ____________________________________ Telephone number Name: ____________________________________ Telephone number and Skills Trainers: Melinda Carlisle Brackett, Licensed Marriage and Family Therapist.

B.

Purpose of Disclosure: Mental Health Treatment Planning and Continuity of Care. Health information that may be used or disclosed through this authorization is as follows: ____Assessment/Treatment/Coordination of Care

C.

Specific Information to be disclosed: By initialing next to a category listed below, I specifically authorize use of confidential information. ____ Psychiatric and Mental Health information as included in the records. ____ Alcohol and Drug Treatment information (Specifically protected under law) ____ AIDS / HIV / other STD testing information (Specifically protected under law) ____ All health information about me as described above, excluding the following: _____________________________________________________________________________________ Specific health information including only: _____________________________________________________________________________________ ____ Mail records certified if indicated by Melinda Carlisle Brackett, LMFT

D.

I give permission to release my records from/until: the following dates: ________________________________________________ (Approximate start date of treatment from provider above) ________________________________________________ (Approximate end date of treatment from provider above)

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

E.

I understand that my records are protected under federal and state confidentiality regulations and can not be disclosed without my written consent unless otherwise provided in the regulations. I also understand that I may revoke this consent in writing at any time, but that in any event this consent expires automatically in 180 days or shall remain in effect for the period of time reasonably needed to complete the request. I understand that I may refuse to sign this authorization and that such refusal will not affect my ability to obtain treatment from Melinda Carlisle Brackett, LMFT. I have read and understand the terms of this authorization. I have had an opportunity to ask questions about the use or disclosure of my health information. I understand that, except when I am receiving health care solely for the purpose of creating information for disclosure to a third party, I may refuse to sign this authorization.

Signature of Client: ____________________________________________________________________________ (Print) Client’s Full Name: _______________________________________________________________________ Client’s Birth Date: ______________________________________ Date: ________________________________ F.

Re-disclosure: If you give us permission to share your information with others, they may share your information about you without your consent. We cannot ensure that your information will be protected by others. However, some instances of State and/or Federal law may protect your information from being shared with others if it is information about HIV/AIDS, mental health, genetics, or drugs/alcohol.

G.

Information about treatment, payment, and insurance: If your written permission to release health information about you is needed to determine your eligibility for medical programs and you do not give us permission to release your health information, then you may not be able to show that you are eligible. If another health care provider has asked us to provide a health care service to you, such as a test or evaluation, and you do not give us permission to release your information to them, then we may not provide you with that health care service.

To the recipients of protected health care information: The information that has been disclosed to you from this authorization is protected by Federal regulations (42 CFR Part 2, 45 CFR Parts 160-164). You are instructed that you may not re-disclose this information without the written authorization from the person to whom the information pertains, or otherwise in accordance with the law.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

DBT GROUP AGREEMENTS 1. Members who drop out of group or individual therapy are out of group. a b

Missing four scheduled weeks in a row of group equals dropping out of group. If a client discontinues weekly individual therapy at any point during DBT Skills Training that client will not be permitted to continue DBT Skills Training.

2. Members are not to lead each other into temptation. a b c d

Members are not to discuss current or past target behaviors or other risky behaviors with other members outside of sessions. Members are not to suggest risky or destructive behaviors to each other. Members are not to come to sessions under the influence of drugs or alcohol. Members under the influence of drugs or alcohol are to come to sessions acting and appearing clean and sober.

3. Members are not to form confidential relationships with each other outside of group. a Members are not to be partners in risky behaviors, crime, or drug use. 4. Members who join the DBT Skills group join the group. a b c d e

Members come to group on time and stay until the end. Members who are going to be late or miss any session call ahead of time. Member who either miss a session without calling or arrive late come to their next individual session prepared to discuss some problem solving to avoid it next time Members validate each other and give helpful, non-critical feedback only when asked. Members keep information obtained during sessions, as well as the names of other members, confidential.

5. Dialectical Agreement: We agree to accept a dialectical philosophy, and, at a minimum, be curious and practice thinking and acting dialectically to the degree that we learn and understand its principals. Your skills trainers agree to model and teach these skills and help everyone practice them in the group sessions. 6. Consultation Agreement: We agree that the primary goal of this group is to improve our own skills as we each make our way in the world. We agree that the spirit of this group is warm, validating, and non-critical. We agree to do our best to assist one another even when we do not share one another’s goals or point of view. 7. Consistency Agreement: Because change is a natural part of life, we agree to accept diversity and change as they naturally come about. This means that we do not have to agree with each others’ positions about how to respond to specific situations, nor do we have to tailor our own behavior to be consistent with everyone else’s. An example of this is that one week one of the facilitators might be unable to attend and the other will fly solo! Change happens and the show must go on! 15

Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

8. Nonjudgmental Agreement: We agree to practice a nonjudgmental stance towards one another and ourselves. We agree to assume that we and others are trying our best and want to improve. We agree to strive to see the world through one another’s eyes even when it is hard. Because judgment will arise in ourselves and others in group we agree to avoid judging the judging and instead to search for a nonjudgmental understanding of what is happening and of other group members’ behavior. 9. Observing Limits Agreement: We agree to observe our own limits. As group members we agree to not judge other members for having different limits from our own (e.g. too broad, too narrow, “just right”). 9. Fallibility Agreement: We agree ahead of time that we are each fallible and make mistakes. Because we are fallible, we agree that we will inevitably violate all these agreements, and when this is done we will rely on one another to point out what’s happened, understand how we came to be where we are, and move toward acceptance and problem solving. This includes your skills trainers and so at any point we invite you to give us feedback so that we may work to skillfully resolve any problems or issues that arise. Rules 1-4 adapted from Skills Training Manual for Borderline Personality Disorder by Marsha M. Linehan, © 1993 Rules 5-10 adapted from Cognitive-Behavioral Treatment for Borderline Personality Disorder by Marsha M. Linehan, © 1993

I agree to the above Group Rules:

____________________________________________________________________________________ Client signature Print Name Date

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

DBT SKILLS TRAINING GROUP DISCLOSURE Over the years of teaching skills training it has become evident that clients may enter class participation with various kinds of expectations about not only the content of the teaching, but also the process of the group and the structure. Therefore it is in everyone’s best interest to outline the general characteristics of the group process and make important distinctions between skills training classes and ordinary psychotherapy process groups. First, DBT Skills Training has as its primary goal, the objective of teaching clients the DBT Skills so that they may then work with their individual therapist to learn how to apply the skills to their very specific target behaviors. The format of the skills training group is classroom style in that participants are expected to take notes and complete homework assignments, and report briefly on the use of skills at the beginning of each module. Unlike other forms of treatment, sharing of homework is limited by the group leader to approximately 2-3 minutes in order to preserve the majority of the group session for teaching and practicing of new material. The Group Leader may raise their hand or otherwise structure a person who is reporting in a lengthy or rambling fashion, in order to help them report more succinctly, which also helps them to develop confidence in this area. Any redirecting that occurs will be done in a non-judgmental fashion. DBT Skills Training differs from other process therapy groups in that members are discouraged from commenting on the thoughts and feelings or stories of other group members. Instead, group members are encouraged to consider all material that is reported in group as simply food for thought, and to consider it in terms of their own use of skills, emotional challenges, and areas of growth. Because maintaining a non-judgmental stance is so critical to creating a safe environment for learning, we teach this throughout all of the modules. Clients should be aware that at no time will personal attacks, threats or other angry interpersonal discussions be acceptable in group session. In fact, no session time will be used to “work out” any interpersonal problems between members. Group members are encouraged to discuss difficulties they may have with others members with their own individual therapist and utilize distress tolerance skills during group sessions, so that the course material presentation can stay on track. Additionally, hostile comments toward the group leaders, challenging the group leaders in an angry way, excessive use of foul language or other excessive negative comments made during group is harmful to the groups sense of safety and will not be tolerated. Such behavior will be treated as therapy interfering behavior, and the group leader reserves the right to terminate the member’s participation in the group. Sessions that the member has paid for but not yet participated in would be refunded within 1 week of termination.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Your DBT Skills Trainers is: Melinda Carlisle Brackett, LMFT #MFC43877

Class Schedule and Group Facilitation: At all times we try to maintain a class schedule for the entire year. However, occasionally changes need to be made to accommodate unexpected events, illness, or travel plans. We will make every effort to notify you of upcoming changes as far in advance as we can. If a schedule change is necessary during a skills module in which you are presently enrolled (which is rare) and causes you to be unable to attend, we will credit you toward another module or refund you for that session. In emergencies, times of unexpected illness, or planned vacations and training, it may become necessary for the group to be led by a single facilitator. The DBT protocol suggests two co-facilitators be present for each skills group session so that in the event one of the facilitators is unable to be present the other facilitator can facilitate the group uninterrupted. It is only in rare circumstance that the group is led by a single facilitator. Both group leaders are qualified to lead DBT groups.

Crisis and the Client’s Individual Psychotherapy: Your group facilitators are there to teach clients the DBT skills as concepts but each client’s individual psychotherapist is the primary resource for the client at all times. In crisis, the client is to notify their psychotherapist and/or follow their therapist’s crisis plan, a copy of which is kept on file with the Skills Training Team. Crisis issues will not be addressed in skills group sessions. If a client attends a skills training session and appears to be in a crisis, they will be escorted out of the skills training session by the skills training leader or co-leader and asked to contact the appropriate resources as previously agreed to by client and their primary psychotherapist, including but not limited to contacting 911. The group skills trainer or co-facilitator will assist the client in making the necessary contact.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Skills Trainers Participate on a Consultation Team As stated in the treatment agreement, your skills trainers participate on a DBT consultation team. This team consists of other intensively trained DBT therapists with whom the therapist can discuss important clinical issues that help your skills trainer and/or DBT therapist be effective at conducting the treatment. Because the role of the consultation team is primarily to help the therapist adhere to the DBT treatment protocol, clients can expect that little clinical information is discussed and only first names used in the discussions as necessary.

I acknowledge that I have read and fully understand the above disclosures. My signature indicates that I have agreed to participate in this DBT Skills Class fully knowing the above terms and conditions. I understand that at any time my skills trainers are willing to discuss these terms and conditions with me and that I can elect to discontinue group if at any time these terms and conditions become unacceptable to me. ____________________________________________________________________________________ Client signature Print Name Date

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

CRISIS PLAN Name of Skills Group Participant:_________________________________________________________ Name of Individual Psychotherapist: ______________________________________________________ Telephone number of individual Psychotherapist:___________________________________________ In a crisis, if I feel that I am in danger of harming myself or someone else, when I am unable to utilize DBT skills to help myself tolerate distress and get through the crisis, or when I need medical assistance of any kind, I agree to implement the following crisis plan: (check all that apply) ___Contact friend or relative:

Name: __________________________ Telephone # ______________

___Contact individual psychotherapist: Name: ___________________ Telephone # _______________ ___Contact Emergency Services or 911 ___Contact Crisis Line: Telephone # _____________________________________________________ I understand that if I attend group with crisis symptoms such as expressing thoughts of suicide or intent to harm myself, my skills trainer or co-leader may, at their discretion contact emergency services or 911.

I acknowledge and agree to abide by the above crisis plan

____________________________________________________________________________________ Client signature Print Name Date ____________________________________________________________________________________ Client's Individual Psychotherapist Print Name Date

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056 NOTICE OF PRIVACY PRACTICES I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH lNFORMATION (PHI) I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I've created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will "use" and "disclose" your PHI. A "use" of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is "disclosed" when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice. However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office. You can also request a copy of this Notice from me, or you can view a copy of it in my office. III. HOW I MAY USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category. A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons: 1. For treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if you are being treated by a psychiatrist, I can disclose your PHI to your psychiatrist in order to coordinate your care. 2. To obtain payment for treatment. Though I am not on any insurance panels and only collect payment from you at the time of service (I do not collect payment from third parties), the law states that I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, theoretically, I could send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims. 3. For health care operations. I can disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to our accountants, attorneys, consultants, and others to make sure I’m complying with applicable laws. 4. Other disclosures. I may also disclose your PHI to others without your consent in certain situations. For example, your consent is not required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056 B. Certain Uses and Disclosures Do Not Require Your Consent. I can use and disclose your PHI without your consent or authorization for the following reasons: 1. When disclosure is required by federal, state or Iocal law; judicial or administrative proceedings; or, law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding. 2. For public health activities. For example, I may have to report information about you to the county coroner. 3. For health oversight activities. For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization. 4. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research. 5. To avoid harm. In order to avoid a serious threat to you or someone else, I may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm. 6. For specific government functions. I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations. 7. For workers' compensation purposes. I may provide PHI in order to comply with workers' compensation laws. 8. Appointment reminders and health related benefits or services. I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer. C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A, B, and C above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven't taken any action in reliance on such authorization) of your PHI by me. IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI You have the following rights with respect to your PHI: A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. I will consider your request, but I am not legally required to accept it. If I accept your request, I will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that I am legally required or allowed to make. B. The Right to Choose How I Send PHI to You. You have the right to ask that I send information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail) I must agree to your request so long as I can easily provide the PHI to you in the format you requested. C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that I have, but you must make the request in writing. If I don't have your PHI but I know who does, I will tell you how to get it. I will respond to you within 30 days of receiving your written request. In certain situations, I

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056 may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. If you request copies of your PHI, I will charge you not more than $.25 for each page. Instead of providing the PHI you requested, I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance. D. The Right to Get a List of the Disclosures I Have Made. You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won't include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request. E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don't file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI. F. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of it. V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. I will take no retaliatory action against you if you file a complaint about my privacy practices. VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: Melinda Carlisle Brackett, M.A. LMFT, Silicon Valley Executive Counseling, 991 West Hedding Suite 106, San Jose CA 95126, Telephone: (408) 893-4032, Email: [email protected], VII. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on April 14, 2003.

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me. If you have any questions about my Notice of Privacy Practices, please contact me at: 991 West Hedding Suite 106, San Jose, CA, 95126 (408) 893-4032. I acknowledge receipt of the Notice of Privacy Practices of the private practice of Melinda Carlisle Brackett, MA, LMFT.

____________________________________________________________________________________ Client signature Print Name Date

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Silicon Valley Executive Counseling Marriage and Family Therapy, A Professional Corporation Melinda Carlisle Brackett, M.A., Licensed Marriage & Family Therapist, MFC 3877 991 West Hedding Suite 106, San Jose, CA 95126 VM: (408) 893-4032 Fax: (408)521-2056

Client Payment Consent Form Patient Name:

___________________________________________________________ Print Last

First

Middle Initial

Name on Card if different ______________________________________________________________________

I authorize Melinda Carlisle Brackett, and Silicon Valley Executive Counseling to charge my credit card for professional services as follows: Please select all that apply and initial in the space provided. ____________

Recurring individual psychotherapy session charges not to exceed $185 per individual session. You may terminate this agreement any time.

____________ DBT Skills group class sessions $75 per session. Skills class fees are payable by the module and are determined by the module length. 6 week modules are $450 and 8 week modules are $600. Payment in full for each module is due regardless of whether or not the client attends all sessions. *Please note that this Credit Card Consent Form becomes part of the clients file on record with Silicon Valley Executive Counseling. Client may revoke this agreement at any time by submitting the request in writing to: [email protected] Type of Card:

□ Visa, □ MasterCard, □ American Express (we do not accept Discover)

Expiration Date: _____________ Security Code:

____________

Credit Card Number:

_______ - _______ - _______ - _______,

Card Holder's Complete Billing Address for Credit Card Statements (Include zip code) ____________________________________________________________________________________________

____________________________________________________________________________________ Card Holder Signature Print Name Date Charges will appear on your credit card statement as “Silicon Valley Executive”.

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