JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Emotional Regulation: A DBT Skills Group
Ages 12-18
WEDNESDAYS @ 6pm
16 week block sessions
Contact
groups@embark-counseling.com
with any questions.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Teen's Name
*
If you are registering more than one child, please complete an additional registration form.
Your answer
All Parent's/Guardian's Name and Phone Numbers
*
Your answer
Address
*
Your answer
Teen's Date of Birth
*
Your answer
Does your teen have any allergies?
*
Your answer
Does your teen have any special needs or accommodations requests?
*
Your answer
Is your teen currently seeing a counselor/therapist?
*
Yes
No
If you answered yes, please provide your counselor/therapist's contact information below.
Your answer
Form of Payment
*
Credit Card (you will be emailed our CC authorization)
Check (Embark must receive payment 2 weeks prior to start date)
Insurance (email
info@embark-counseling.com
to see if your insurance covers this group)
Paying per session or in full?
*
In Full - $544 (savings of $96)
Per Session - $40 (16 week commitment)
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Embark Counseling Services, LLC.
Report Abuse
Forms
