RO DBT Treatment Program Interest Form

The following form will help determine if Radically Open DBT is the best treatment for you and add you to the waitlist to be assigned an individual therapist. We take great pride in providing each of our clients with specialized care. RO DBT is a cutting edge and highly effective treatment, please note that waiting times may be longer than 2 months.

If you are seeking traditional DBT or are unsure what RO DBT is, please visit this page first before proceeding: What is RO DBT?

If you already have an individual therapist and are seeking to join RO DBT Skills Class only, please register here: Skills Class Only

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* 1. How did you learn about Radically Open DBT?

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* 2. Individuals often pursue RO DBT therapy when they have troubling thoughts, emotions or problems in relationships . Please select all of the symptoms you have experienced in the last year?

Prolonged depression, apathy or down mood

Prolonged worry or rumination

Obsessive thoughts - frequent intrusive unwanted thoughts or images

Compulsive behaviors - strong desire for repetitive behavior such as checking, ordering, cleaning, sorting, etc.

Restricted eating, over-exercise, or binge-purge behavior

Social anxiety, isolation or lack of social connectedness

Outbursts in private - emotional outbursts (i.e. anger, sadness) only when alone or with people in your immediate family/romantic partners

Rigid, rule governed, or stubborn behavior

Striving for perfection

Difficulty expressing honest and vulnerable thoughts and feelings to others

Difficulty labeling or understanding other's non-verbal social cues

Feelings of loneliness or exclusion

Intolerant of mistakes or changes in plans

Insisting that processes are done the 'right way'

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* 3. Radically Open DBT is a treatment designed for individuals who have an over-controlled temperament type. Individuals with over-control temperament are often described as detail oriented, guarded, rigid, perfectionistic, hard working, anxious and prone to loneliness. Does this style describe you?

Yes, the over-control style describes me

No, this does not describe me

I don't know, I need additional information to decide.

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* 4. The following symptoms are not indicated for treatment with RO DBT. Have you experienced any of these in the past year?

Addiction - physical or chemical dependence on a substance not prescribed to you by a doctor

Psychosis - seeing/hearing/sensing/believing things that other people tell you is not real

Mania - intense periods of energy and elated mood that result in destructive behavior, typically a part of bipolar disorder

Destructive to Property/Harm to Others - actions or strong urges to destroy property or harm another person

Outbursts in Public - emotional outbursts (i.e. anger, sadness) in public places or directed at people outside of your immediate family/romantic partners

None of the above

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* 5. Radically Open DBT treatment consists of weekly individual therapy sessions and weekly skills class meetings for approximately 30 weeks. This combination of individual therapy and class is an essential component to learning and living in a skillful way.

Yes, I would like to participate in the full program of weekly sessions and skills class

I already have an individual therapist and would like to join skills class only.

I don't know. I would like more information before making a decision.

Other (please specify)

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* 6. Radically Open DBT is a structured and active form of therapy. When working with an RO DBT therapist you will be asked to:
- track your thoughts, moods, and social signals daily on a diary card
- engage in skills class discussion and activities
- independently practice skills and self-enquiry between sessions
- commit to not acting on self-harm thoughts
- complete self-care independently such as grooming, nutrition, medication, and leaving the home

How willing or able are you to commit to these agreements during treatment?

A great deal

A lot

A moderate amount

A little

None at all

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* 7. Please provide information about yourself and a member of our team will follow-up with you.

Name *

Address

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number

RO DBT Treatment Program Interest Form

Question Title

* 1. How did you learn about Radically Open DBT?

Question Title

* 2. Individuals often pursue RO DBT therapy when they have troubling thoughts, emotions or problems in relationships . Please select all of the symptoms you have experienced in the last year?

Question Title

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* 4. The following symptoms are not indicated for treatment with RO DBT. Have you experienced any of these in the past year?

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* 5. Radically Open DBT treatment consists of weekly individual therapy sessions and weekly skills class meetings for approximately 30 weeks. This combination of individual therapy and class is an essential component to learning and living in a skillful way.

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* 7. Please provide information about yourself and a member of our team will follow-up with you.

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* 8. Is there additional information you would like us to know as we consider your application?