Email Form

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 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

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?

	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?