DBT Skills Group for Queer and Trans Folx Interest Form
Thank you for your interest in the 2024 DBT Skills Group for Queer and Trans Folx at Radical Healing. 

We are excited to re-boot this popular and much needed group. If you're interested in being contacted when our groups open up registration, please complete the following form. 

Our next round of DBT Skills for Queer and Trans Folx will be Saturdays, 10:00A-11:30AM beginning June 1, 2024 and will be co-facilitated by Samara Brown, LCMHC and Ray Barnhart, LCSW.

Since this form is transmitted electronically, confidentiality cannot be guaranteed. If there is any question you prefer not to answer, please let us know by completing the last form response and we can schedule a time to meet with you over the phone or in person.
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Name (what we should call you) *
Pronouns *
Race/Ethnicity (This question helps us ensure we create safe-r healing environments by ensuring we have a diverse community represented in our group.) *
Birthday *
MM
/
DD
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YYYY
Phone Number *
Address
Email *
Emergency Contact (Name, Relationship, Phone #) *
Do we have your consent to...(the more options you leave for us - the easier it is for us to get in touch w/ you!) *
Required
How did you hear about us?
What are you hoping to learn or gain from the skills group experience?
Are you interested in our online or in-person group?
Clear selection
What concerns do you have about group?
Have you ever participated in a counseling group or skills group in the past?
Clear selection
If yes, briefly explain
Are you currently seeing an individual therapist? If no, have you seen an individual therapist in the past? If yes, please provide the name of your current therapist. *
Do you currently experience the urge to self-harm (cutting, scratching, hitting, burning, etc.) and/or engage in self-harm regularly?   Have you had these urges or engaged in self-harm within the last year? *
Do you currently and/or within the past year experience suicidal thoughts that include plans and intention on acting out those plans?  Have you had any suicide attempts in your life? *
Do you currently and/or within the past year experience urges to physically harm others and/or have you acted out physical aggression towards others? *
Please indicate whether you can afford to pay the full fee ($60 per meeting, including meetings that you miss), or if you would like to be considered for financial assistance and scholarship.  We have limited assistance that we can offer to folx who would otherwise not be able to participate.  Please note that paying the full fee allows for us to fund others who cannot access treatment. If you'd like financial assistance, please indicate how much you can afford to pay per meeting.  Tuition is required for all group sessions regardless of attendance. *
Would you prefer to meet in-person for group (location would be in our group room in our Durham office), or prefer to meet virtually? *
Do you think you can commit to meeting weekly for 1.5 hours for at least 6 months?  If not, what are some hurdles that may get in the way? *
Do you have any accessibility needs or special considerations that can make the learning environment more accessible for you?
If you have general questions for the facilitators, any comments, or anything you would like to share with us, please provide it here.  
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