MBCT For Couples Registration Contact Form

Designated Partner

All billing will be under this partner. The designated partner may not be changed once provided.

First Name

Last Name

Email

Cell Phone

Diagnosis

Required If You Will File For Out-of-Network Insurance Benefits. Indicate NA Otherwise. NOTE: Out-of-Network benefits are not available for participants in Mindfulness for Couples in Helping Professions.

Partner

First Name

Last Name

Email

Cell Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name three things you want to improve in your relationship as a result of taking this class

Agreement to Terms & Conditions

We certify we both have read and understand the terms and conditions below. By submitting this form, we agree to all the terms and conditions.

We certify that we have both read the Mindfulness for Couples webpage in full

We certify that we both will participate in a 30 minute orientation and come prepared with questions

Participating Couples Agree To:

We both have read and understand the entire Mindfulness for Couples in Helping Professions webpage.

We agree to both participate in a 30-minute individual orientation to be scheduled with the instructor. We will come to the orientation prepared to ask any questions we have, discuss our expectations for the class and learn more about what the class entails.

We commit to attend all ten sessions, an all-day Saturday retreat and three individual consultations for a total of 11 group sessions plus 3 individual consultations over 10 weeks. We understand that each session builds on previous sessions and that any absence affects our progress and the quality of other participants’ experience.

We commit to practice meditation, mindful activity and noticing a different type of thought daily between sessions. Home practice will require about 20 minutes a day six days a week. We understand progress hinges on regular practice.

We commit to track the mindfulness skills each of us uses daily on the provided MBCT Diary Cards.

We understand that in-class practice exercises may on occasion cause emotional discomfort. We understand therapist will minimize emotional discomfort as much as possible but we accept that some discomfort may be unavoidable and useful.

We commit to use coaching calls if/when I/we have the urge to stop coming to class, skip a class because I/we had a bad day, when I/we become dysregulated because of something that occurs in class, when I/we are struggling with initiating home practice or if other class-related or mindfulness-related concerns, questions or struggles arise.

If applicable, we understand that a diagnosis is required for the designated client whose insurance will be used to file for out-of-network benefits. We further understand the designated client may not be changed once provided.

If applicable, I/we certify that all mental health providers I/we see are aware of our intent to participate in an Mindfulness-Based Cognitive Therapy class and support my participation.

If under psychiatric care or in therapy, I/we commit to continue under care and follow treatment recommendations throughout the 10 weeks of the class.

We have a working computer or device with access to high-speed internet and working camera, speakers and microphone. Cell phone access is not recommended.

We consent to recording of group sessions. We further consent to have audio recordings distributed among group members.

We agree to pay a $120 non-refundable registration fee which will cover the cost of the orientation, three individual consults, the book, the weekly Odds & Ends newsletter, between session coaching and the textbook.

We give St. Louis DBT, LLC permission to bill my credit or debit card for $120/session for 11 sessions, which includes 10 weekly sessions plus a 6 hour retreat One partial scholarship is available upon written application. Deadline for a scholarship is May 20. Scholarship is awarded on a first come, first served basis.

We understand that we are purchasing a full course for a total cost of $1320. The cost is prorated over 11 sessions solely for the convenience of participants. Participants may elect to pay in full at any time.

We agree t0 provide credit or debit card details either through St Louis DBT’s client portal or by phone prior to this application being accepted. Credit card details will be saved in ST. Louis DBT, LLC’s secure and private electronic records management system, TheraNest.

We understand St. Louis DBT, LLC does not file health insurance forms but that documentation can be provided on request so the designated client can submit for out-of-network reimbursement, if available. Diagnosis must be provided by the designated client’s therapist. We understand insurance providers will not reimburse for missed sessions. We understand that once the designated partner is named it cannot be changed. Note: Mindfulness for Couples in Helping Professions is not eligible for out-of-network benefits.