Dialectical Behavior Therapy (DBT) Questionnaire

Thank you for your interest in Dialectical Behavior Therapy! Please answer the following questions so we can prepare for a consultation call to see if it might be a good fit for you.

First Name *

Last Name *

Phone *

Email *

How did you learn about DBT? *

How did you learn about our clinic? *

What problems or struggles are you hoping to work through with DBT? *

Are you currently seeing a therapist regularly? *

Yes

Do you prefer Daytime or Evening appointments and groups? *

Daytime

Evening

Either

Which DBT group format are you most interested in? (check all that apply)

Standard 2 hour format

Low fee 1 hour format

Managing Emotions accelerated DBT

Teen DBT

Unmasking Neurodivergence (DBT-Informed)

What questions do you have about DBT or about our clinic?

Fees associated with Dialectical Behavior Therapy

DBT is an investment in your self and your mental health. DBT is the gold standard treatment for out-of-control emotions and can offer lasting benefit.

The elements of our DBT Program include the following:

Psychological Intake, 90 min, one time fee of $300
DBT Skills Group, $85-115/week depending on group and payment plan
Individual therapy, ranges from $175-250 per session depending on the provider
DBT App - FREE
Coaching calls - FREE
Skills Binder - FREE

A full cycle of DBT Skills Group includes 3 modules which are designed to work together. We do not recommend taking just one module.

You may apply for a rate reduction by completing the questions in the next section.

This section is optional.

What is your annual Household Income?

Are there other people you are financially supporting? Please describe.

What other sources of financial support do you have?

Do you have out of network insurance benefits? Please describe.

What is your total budget for KAP services?

Are there any extenuating circumstances we should consider? Please describe.

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