DBT Program Referral

DBT Program Referral Form

Please complete the following form to refer a client to our Dialectical Behavioral Therapy (DBT) program. After this form is submitted, our DBT Treatment Team will meet to discuss the referral and set up a DBT intake assessment appointment. If your client is accepted, we will contact you to discuss consultation.

Please keep in mind that DBT is contraindicated for individuals with antisocial personality disorder or narcissistic personality disorder.

If you have any questions, please contact Mood Treatment Center for more information.

Client's Name

Client's Date of Birth

Referring Clinician

Reason for the Referral

Current Diagnosis and Rule Outs

Have you talked to them about DBT? Are they able to commit to the 6 month requirement?

Previous treatment history and/or DBT experience

History of hopsitalization and/or ER visits for MH/SA

Please describe any history of SI/Self-Harm behavior and impulsivity

Please describe any history of anger/agressiveness

History of criminal activity

History of trauma

Client's Email and/or Phone Number

Clients Preferred Method of Contact

Phone