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
No
Yes
(detailed messages OK?)
Your Phone Number #2
(
)
-
private voice mail
No
Yes
Your Email Address
How did you find out about our clinic?
Google
other search engine or web page
Amen Clinic
Aurora
BehavioralTech
BPD Global
Center for Discovery
National Education Alliance-BPD
Practical Recovery
San Diego Psychological Association
Sharp Mesa Vista
UCSD Child Adolescent Psych
UCSD Eating Disorders Program
a DBT client
a research study
other
therapist or clinic
Name of therapist or clinic:
Who is seeking services at our clinic
Me
my parent
my child
my sibling
my family member
my friend
my patient
other
No
Yes
Currently have an individual psychotherapist or counselor?
No
Yes
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?
I don't know
depression
bipolar disorder
social anxiety
panic disorder
post-traumatic stress disorder
other anxiety disorder
anorexia
bulimia
other eating disorder
borderline personality disorder
borderline personality traits
other personality disorder
psychotic disorder
other disorder
marital problems
family problems
someone else with challenging problems
Insurance Company
None
Aetna HMO
Aetna PPO
Anthem Blue Cross HMO
Anthem Blue Cross PPO
Blue Cross Blue Shield
HealthNet
PacifiCare
Tri-Care Tri-West
United Behavioral Health
Value Options
Veteran Affairs
MediCal-Medicare
Other
Therapist gender preference?
first available - no gender preference
not willing to have male therapist
not willing to have female therapist
What days and times are you
NOT
available for sessions?
Morning
Afternoon
Monday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
thru
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
thru
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
Tuesday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
thru
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
thru
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
Wednesday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
thru
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
thru
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
Thursday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
thru
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
thru
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
Friday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
thru
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
thru
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
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