DBT SKILLS GROUP APPLICATION

Name

Phone

Email

Do you live in New York State?

Yes

No

Sometimes

Do you currently attend individual therapy on a regular basis?

Yes

No

From whom/where did you hear about the program?

If you are currently attending individual therapy, who is your individual therapist?

If you are currently attending individual therapy, how often do you meet with your therapist?

Have you ever attended a DBT skills group?

Yes

No

If so, for how long, and what was covered?

Why are you currently seeking a skills group?

What are you able to pay per meeting/week? Please review information about the tiered pricing of DBT skills groups at bit.ly/DBTGroupFees before choosing.

Please describe your current financial and employment situation. As noted above, we prioritize those with low and/or unreliable income for lower fees; we appreciate any further information you think is relevant.

Which groups are you interested in attending?

DBT Skills for Addictive Behaviors Group (4 weeks)

DBT Skills for Emotional Regulation (15 weeks)

DBT Mindfulness Skills Group (12 weeks)

Abbreviated DBT Skills Group (14 weeks)

Standard DBT Skills Group (24 weeks)

Graduate DBT Skills Group

Any

Not Sure

How long would you like to be on this waitlist?