Legal Name
Preferred Name
Please rate the following statements on a 0-5 scale (0 = not at all; 5 = very much):
I am here because I want to be (not solely because someone else wants me to be.)
Group sounds really interesting.
I wish I could change painful aspects of my life.
I think learning DBT skill will help me change problematic behaviors.
Please briefly describe your (or your parents') general reasons for seeking out DBT Group:
What emotions or behaviors cause problems for you?
What changes do you hope to see as a result of DBT Group?
Tell us about your interactions with peers in other group settings (i.e., classroom, extracurricular, friend group, etc.):
What concerns do you have about group?
What would help make group a positive experience for you?
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