DBT Skills Group Referral Form

Client Name

First Name

Last Name

DOB

Client/Guardian Email

Client Contact Phone

(###)

###

####

Name of Insurance Company

Member ID

Subscriber Name (If under parent or spouse’s insurance)

Subscriber Address

Subscriber DOB

Referral Contact Information

Message

Adult DBT Group

TBD

PLEASE EMAIL A COPY OF THE FRONT AND BACK OF YOUR INSURANCECARD AND PHOTO ID (WE CANNOT BILL INSURANCE CLAIMS WITHOUT THIS)

*If you have a current individual therapist please email us a Release of Information Form and current Treatment Plan with a DBT group goal.

Intake Forms and Consents will be sent electronically upon receipt of this form.