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 Full Name:
Client's Phone Number:
Date of Birth:
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
PortageMadisonTelehealth only, which is available temporarily
Track 1: DBT Skills Training GroupTrack 2: Full Adherent Program. This includes meeting with a DBT therapist individually, participating in the DBT Skills Training Group, and receiving skills coaching.
Intense Emotional Reactivity
If checked above what type of emotional reactivity?
AngerIrritationRageSadnessLow MoodHopelessnessWorthlessnessApathyManiaAnxietyHigh MoodOther
Experience of emotions quickly shiftingDifficulties managing stressful situationsProblems communicating needs and wants effectively with othersExperiences crises oftenEngages in self-harmEngages in other impulsive actions
If checked above, what kind of impulsive actions?
Suicidal thoughtsThoughts of harming othersLow sense of selfDifficulties with sleepDifficulties with organizationDifficulties with focus/concentrationLow AppetiteLarge Appetite
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: