DBT Center of San Diego
Request a First Session

Submit the following information and we will contact you promptly to answer your questions and schedule a first session.
You may call us and leave a message (619-602-0726), but you will generally get a quicker response by submitting this form.

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 therapyNeed Dialectical Behavior TherapyNeed 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

Would you like to be contacted about research studies for which participants are paid or receive free therapy?

Therapist gender preference?

What days and times are you NOT available for sessions?
MorningAfternoon
Monday thru thru
Tuesday thru thru
Wednesday thru thru
Thursday thru thru
Friday thru thru

Please enter your Email address again


Anything Else?