Maine DBT Center Application Form

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Maine DBT Center Application Form

After you have submitted this form, your name will be added to our waiting list and you will receive a confirmation notice. When your name comes up, you will be contacted by the next available clinician who will make an appointment for an assessment to determine your eligibility.

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* Indicates required question

Email *

Your email

Name *

Your answer

Date of Birth (This program is for adults only.)
*

Your answer

Address
*

Your answer

Phone number
*

Your answer

Name of insurance
*

Your answer

Scheduling needs for individual sessions
*

Your answer

Who referred you to us?
*

Your answer

A copy of your responses will be emailed to the address you provided.

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