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DBT-C Interest Form
Please complete the form below and a member of our team will contact you to further discuss the DBT-C program.
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* Indicates required question
Email
*
Your email
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Is the child currently receiving therapy?
*
Yes
No
If you answered yes to the previous question, who is the provider?
*
Your answer
What brought you to inquire about DBT-C?
*
Your answer
Parent/Guardian #1 Name
*
Your answer
Parent/Guardian #1 Phone Number
*
Your answer
Parent/Guardian #1 Email
*
Your answer
Parent/Guardian #2 Name (if applicable)
*
Your answer
Parent/Guardian #2 Phone Number (if applicable)
*
Your answer
Parent/Guardian #2 Email (if applicable)
*
Your answer
Is parent/guardian currently receiving therapy?
*
Yes
No
If you answered yes to the previous question, who is the provider?
*
Your answer
How did you hear about us?
*
Mental Health Provider
Family/Friend
Flyer
Website
Social Media
Other
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