DBT Skills Group for Teens

DBT Skills Group for Teens

Registration Form
Description: Dialectical Behavioral Therapy (DBT) Skills Group is a classroom-like environment where teens learn ways of handling distress, regulating emotions, engaging in mindfulness, and interacting more effectively. In this space, teens focus on learning skills and discussing ways of applying them more effectively in their daily life.

Cost: Each group session will cost $40. Clients are required to have a card on file with the practice. We are unable to bill this service to insurance at this time.
Name

First NameLast Name
Preferred Pronouns
Are you a former or current KCC client?
Do you currently work with an individual therapist using DBT?
Can you consistently attend meetings on Tuesdays from 6:00-7:30pm?
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Name

First NameLast Name
Guardian Email
example@example.com
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

In order to join our DBT Skills Group, you must attend an orientation session with our group coordinator. You may be required to pull your teen out of school depending on availability. Please select all times you would be available to schedule this meeting:

Rows	10AM	11AM	12PM	2PM	3PM	4PM	5PM
Monday
Tuesday
Wednesday
Thursday

Is there anyone you would be uncomfortable being in Skills Group with? Please provide their name(s).
Is there anything you want our group leaders to know before the first group session?
Contact Genevieve Stafford, our Group Coordinator, with any questions.

Genevieve@kernersvillecounseling.com

336-283-3830
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