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

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

* 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?

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

* 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.)

* 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?