DBT Skills Group for Adults

DBT Skills Group for Adults

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

Cost: $40 for each group session. 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 Thursdays from 5:30-7:00PM?*

YesNo
Client Date of Birth*

MonthDayYear
Date
Client Email*
example@example.com
Client 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 take time off work 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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