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?*

YesNo
Do you currently work with an individual therapist using DBT?*

YesNo
Can you consistently attend meetings on Tuesdays from 6:00-7:30pm?*

YesNo
Client Date of Birth*

MonthDayYear
Date
Client Email*
example@example.com
Client Phone Number*
Please enter a valid phone number.
Guardian Name*

First NameLast Name
Guardian Email*
example@example.com
Guardian Phone Number*
Please enter a valid phone number.

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:*

	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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