Dialectical Behavior Therapy Group for Teens

Question Title

* 1. Please provide the following information so that we may send you details about this group.

Today's date

Name:

Age:

Phone:

E-mail:

Address:

Parent/Guardian's Name:

Question Title

* 2. DBT group is most beneficial when combined with individual therapy. Are you currently in individual therapy?

Yes

No

Not yet, but I plan to.

Please help me find one.

comments

Question Title

* 3. DBT requires consistency, both for your benefit and the success of the group members. We ask that you will be able to attend at least 8 of the 9 groups that meet on Wednesday nights (understanding that emergencies may arise). Would you be able to attend group every Wednesday from 5:30 - 6:30pm?

I will commit to attending at least 8 of the 9 weeks of group.

I have specific days that I already plan to be out of town. I will let you know those days on the first day of group.

Question Title

* 4. Please give a short explanation about why you want to be involved in DBT group:

Question Title

* 5. Groups are covered by most insurance plans and we can check your benefits for you to see if you qualify. Please provide the following information and we will get back to you with the costs. (enter N/A if you are not covered by major medical.)

Name of insurance company.

Customer service number.

Group number.

Member ID number.

Date of birth.

Question Title

* 6. If you are not covered by a major medical insurance, the cost for group will be $30.00 per session. Will you need assistance/sliding scale?

Yes, I'd like to request sliding scale.

No, I will self pay at $30 a session.