DBT Skills Group Screening Form

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If you are interested in DBT Skills Group, please complete this complimentary screening form. Please expect a response in 48 business hours. Please email any questions to info@flowps.com

Name (preferred first name and legal last name) *

Email *

Date of Birth *

YYYY

Are you filling out this form with assistance? If so, will you need this person to be copied on any communication having to do with scheduling and attending group so that you can attend and be present consistently? Please provide their email if you would like us to cc: them copies of the consent and scheduling forms.

Why do you want to do this group? (write as much as you would feel comfortable sharing; Please note that Dr. Brook is a mandatory reporter and may be required to report any abuse or neglect of a person under 18, disabled adult, or person 65+ to authorities).

What do you hope to achieve from being in this group?

Do you have any history of learning difficulties that may interfere with keeping up in a group education setting that moves at a typical pace? If so, what are they?

Are there any mental health, medical, or other factors that would interfere with participating in a weekly skills group online? If so, what are they?

Do you have any communication needs that we should know about? If so, what are they?

Do you have Lyra Health Benefits?

Yes

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I understand that this group is private pay, unless I have Lyra Health benefits. The cost of the group is a $300 intake session due at the time of the session followed by three subsequent installments of $800 due before the start of each of the three 8-week modules. The total cost is $2700. Once I have paid tuition for a module, I understand that there will be no refunds. I understand that Dr. Brook / Flow Psychological Services is out of network with insurance companies other than Lyra Health. If I have Lyra Health benefits, I understand that I may choose to use Lyra benefits for individual and group sessions up to the limit of my Lyra coverage. I also may choose to private pay for group sessions to save my Lyra sessions for more expensive individual therapy. Either way, after my Lyra EAP sessions have been used up, I may be able to use my insurance through Lyra if my Lyra coverage allows. If not, I will switch to private pay after my Lyra benefit is used up. I understand that Flow Psychological Services is out of network with any other insurance companies. For any sessions I pay and attend, Flow Psychological Services can offer a superbill to me to provide to my insurance company. I agree that Flow Psychological Services is not responsible to assist me with insurance beyond providing a superbill. *

Yes

I understand that the group is a 24-week commitment. *

Yes

I understand that this is a psychoeducational group to learn new skills and is not a substitute for individual therapy. *

Yes

Are you actively involved in individual therapy? *

Yes

I understand that the following risk factors - suicidal ideation, homicidal ideation, or self-harming behavior - require me to have an individual therapist who I meet with weekly and who signs an agreement that they take primary clinical responsibility for my care and will manage any crises that arise. I must also sign a release for Flow Psychological Services to communicate with that therapist as necessary. If I have no risk factors, having an outside therapist is recommended but not necessary. It is possible that I will develop these risk factors while in the group. If so, I agree that I will follow these rules: within 2 weeks, find an individual therapist who I meet with weekly and who takes primary clinical responsibility for my care, and provide authorization for this therapist and Flow Psychological Services to communicate. *

Yes

I understand that due to licensure limitations, I may only participate when I am physically located in the states of California, Colorado, Florida, or Nevada. *

Yes

I understand that I must have a private space where others cannot overhear or see my device screen. *

Yes

I understand that I must have consistent and stable access to the internet and Zoom. *

Yes

Is there any other information that you would like Flow Psychological Services / Dr. Brook to know at this time?

Please make sure that you click submit when you are ready to have Flow Psychological Services / Dr. Brook view this form (you should receive a confirmation). Please double check your email and contact information to ensure it is correct.

There may be occasional times when my email goes to your spam folder. Please feel free to email info@flowps.com

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