Email Form

DBT Center of San Diego
Wait List

Unfortunately, our licensed therapists may not have any openings for new clients until June 2020. We apologize for the delay. If you would like to add yourself to our wait list please complete this electronic form, and we will contact you when we are able to schedule your intake. Tell us below if your schedule is flexible because times earlier in the day often open up sooner. Times in the evening or late afternoon often take much longer to open up.
We expect our unlicensed therapist to continue to have openings for new clients, without much delay.

Your Name
Your Clinic or Agency
Your Phone Number #1	() - private voice mail (detailed messages OK?)
Your Phone Number #2	() - private voice mail
Your Email Address

How did you find out about our clinic?
Name of therapist or clinic:

Who is seeking services at our clinic

Currently have an individual psychotherapist or counselor?
If yes, is the plan to end with this therapist end when starting therapy at our clinic?

How old is the person seeking services?

What services are needed from us?

Not yet sure about therapy	Need Dialectical Behavior Therapy	Need therapy or other services
I don't know	Standard DBT (individual + group)	Cognitive Behavioral Therapy
BPD diagnosis	DBT skills training group only	Biofeedback emotion regulation training
BPD and bipolar diagnoses	Individual DBT (without group)	Biofeedback stress management
full diagnosis interview	DBT for adolescents and families	Parent training group
	help me deal more effectively with
	someone with challenging problems

For what primary problem?

Insurance Company

Are you willing to work with an unlicensed male therapist (lower fee)?

What days and times are you NOT available for sessions?

	Morning	Afternoon
Monday	thru	thru
Tuesday	thru	thru
Wednesday	thru	thru
Thursday	thru	thru
Friday	thru	thru

Please enter your Email address again

Anything Else?