External Provider’s Referral Form: Dialectical Behavior Therapy (DBT)

    Referring Provider's Information
    Date of Referral:

    Referring Provider Full Name:

    Referring Provider Email:

    Referring Provider Facility Address:

    Referring Provider Facility Phone:

    Referring Provider Facility Fax:

    Client's Information
    Client's Full Name:

    Client's Email:

    Client's Phone Number:

    Date of Birth:

    Insurance Company:


    Current Treatment Modalities:
    (Please include individual therapist, psychiatry, psychologist, psychiatrist and type of treatment):


    Currently, all services are being offered/rendered via telehealth, although it is unclear how long remote delivery will continue. The following reflect physical locations where groups have historically been available

    Program Option:

    Presenting Concerns:

    Symptom Checklist:

    If checked above what type of emotional reactivity?

    Symptoms (continued):

    If checked above, what kind of impulsive actions?

    Symptoms (continued):

    History of Life Threatening Behaviors:
    Has the client attempted suicide in the past?

    If answered yes, when was the most recent attempt?

    Has the client engaged in self-harm?

    If answered yes, when was the most recent self-harm behavior?

    Has the client been hospitalized?

    If answered yes, when was the most recent hospitalization?

    Other Significant History (Include Trauma here):

    Other Pertinent Information:

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