Child Treatment Request Form

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Email *

Child's Name (first and last): *

This referral form must be completed by a parent/guardian of the potential client.

Family members/friends/other invested parties are not permitted to complete this form without the parent/guardian's direct input.

I certify that I am the parent/guardian of the identified potential client and will complete this form on my own or will actively participate in completing this form with another trusted party.

Greenville DBT Collective does not accept insurance.

We are able to provide superbills for out-of-network reimbursement when/if clients begin treatment. The responsibility of submitting these superbills falls on the family.

Please visit our website to view our fees.

I understand that I will need to self pay for my child/teen's initial assessment with Greenville DBT Collective.

By completing and submitting the subsequent information, you are consenting to have your child added to the Greenville DBT Collective waitlist.

If you do not wish for your child to be added to our waitlist, please do not complete the following form.

If you have any questions prior to completing this form, please leave a message for our referral coordinator at (864) 501-4098.

I consent to having my child added to the Greenville DBT Collective waitlist.

Today's date
*

YYYY

Child's preferred name:

Child's date of birth:
*

YYYY

Child's age:
*

Child's address:
*

Parent/guardian's name:
*

Parent/guardian's phone number:
*

Parent/guardian's email: *

Who referred you to Greenville DBT Collective?
*

Has your child been hospitalized for mental health reasons? If so, how many times?
*

Child's current psychiatrist:

Child's current therapist:

Does your child have any known mental health diagnoses? If so, please describe

Is your child having behavioral problems at school? If yes, please describe.

Is your child having behavioral problems at home or other environments? If yes, please describe.

Is there anything else you would like us to know?

Submit

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