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DBT Group Referral Form
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* Indicates required question
Email
*
Your email
Referring Provider
*
Your answer
Provider phone number
*
Your answer
Provider email
*
Your answer
Client name
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Parent name
*
Your answer
Current mailing address
*
Your answer
Client phone number
*
Your answer
Client email
*
Your answer
Client's current diagnosis (es)
*
Your answer
Current psychiatric medications
*
Your answer
Does this client have an individual psychotherapist?
*
Yes
No
If "yes" please provide name and contact information.
*
Your answer
How long has this client been in therapy?
*
Your answer
Insurance Information
Your answer
What is their current treatment plan?
*
Your answer
Does this patient have any of the following history or behaviors? select all that apply
*
Self-harm
Suicide attempts
Substance abuse
Eating disorder
Other impulsive/aggressive behaviors
Required
Have you discussed DBT with the client (and his/her parent)?
*
Your answer
Is the client familiar with DBT?
*
Your answer
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