DBT Skills Group Interest Form

DBT Skills Group Interest Form - Teens
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.
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
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.

What days/times are you available to attend group? (select all that apply)*

Is there anyone you would be uncomfortable being in Skills Group with? Please provide their name(s).
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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DBT Skills Group Interest Form - Teens