ADBTA Service Request Form

ADBTA Service Request Form
At our practice, we offer a variety of services to meet your needs. The first step to enrolling with us is to complete an initial intake assessment. Please fill out the form below and one of our practice managers will get back to you shortly to discuss scheduling an appointment.

If you have any issues with our request forms or our website, please email hello@austindbtassociates.com or call/text us at 512-902-3282.
Are you looking into services for yourself or another adult?*

Yes, myselfYes, another adultNo, an adolescent

Are you looking into services for a teen?*

Yes, Currently in High SchoolYes, Currently in Middle SchoolNoMy teen is under 11 years old, please add them to the waitlist.
What services are you/they interested in?*

Individual CounselingCouples CounselingParent CoachingFamily CounselingMedication ManagementGroup Skills Class
Do you/they already have an individual therapist you/they are seeing for one-on-one sessions?*

YesNo
Please list your therapist's name.
What office location works best for you?
Austin office (4601 Spicewood Springs Rd, Bldg 3, Suite 100, Austin, TX 78759)
Virtual Only
Either/First Available*
We offer different types of DBT skills classes that are specialized to meet the needs of adults, adolescents and their parents. A clinician can help you identify which type of skills class would be best for you.
- DBT (The original treatment developed for adults and adolescents who have difficulty managing emotions and impulsive behavior.)
- RO-DBT (A subtype of DBT for adults and adolescents who have difficulty managing emotions, but are more likely to control their emotions by hiding or masking them in front of others and struggle with perfectionism or rigidity.)
- Graduate RO-DBT You’ve successfully completed an RODBT skill class—now, it's time to continue deepening your skills practice and learning from how it shapes your daily life and impacts your relationships and valued goals. Our group for RODBT graduates will offer community as well as accountability for practicing skills that support us in meeting life with openness, flexibility, and connection. Whether you're looking to stay connected to your growth journey or tackle new emotional challenges, this group will help you keep thriving.
- Parent Skills (A psychoeducation class for parents seeking to support their adolescent or young adult children who have difficulty managing emotions.
- Summer Boot Camp for Young Adults (18 to 24 year olds)Summer is a great time to shape-up skillful behavior and cope ahead for a new school year! ADBTA is offering 4 week DBT Skills Boot Camps for a young adults (18-22) who are home from college and would benefit from a "skills refresher" and/or additional support.
Are you interested in joining one of our adult group skills classes?*

YesNo
Here is a list of our current group skills classes (Please choose a few schedule options, if your schedule allows. Your selection does not guarantee an immediate space in group, some of our offerings are full and on a waiting list. This will be discussed with you at scheduling)*

DBT Monday 4:30-6pm (Austin, in person)DBT Tuesday 12-1:30pm (Virtual)DBT Tuesday 5:30-7pm (Virtual)DBT Wednesday 5-6:30pm (Austin, in person)DBT Wednesday 6-7:30pm (Virtual)DBT Thursday 12:30-2pm (Austin, in person)DBT Thursday 6-7:30 (Austin, in person)DBT Thursday 6:30-8pm (Virtual)RO-DBT Monday 12-1:30pm (Virtual)RO-DBT Tuesday 6-7:30pm (Austin, in person)Graduate RO-DBT Thursday 12-1:30pm (Virtual)RO-DBT Thursday 4:30-6pm (Austin, in person)Parent/Family Skills Wednesday 12-1pm (Virtual)DBT Substance Use (schedule TBD)None of these work for me.
Is there an individual therapist you/they are seeing for one-on-one sessions?*

YesNo
Please list your therapist's name.
What services are you/they interested in?*

Individual CounselingGroup Skills ClassesMedication management
What office location works best for you?
Austin office (4601 Spicewood Springs Rd, Bldg III, Ste. 100, Austin, TX 78759)
Virtual Only   Either/First Available*

Are there any time preferences? (We'll do our best to accommodate your needs to the best of our ability)*

	8a-12p	12p-4p	4p-8p
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend

We offer different types of DBT skills classes that are specialized to meet the needs of adults, adolescents and their parents. A clinician can help you identify which type of skills class would be best for you.
- DBT (The original treatment developed for adults and adolescents who have difficulty managing emotions and impulsive behavior.)
- RO-DBT (A subtype of DBT for adults and adolescents who have difficulty managing emotions, but are more likely to control their emotions by hiding or masking them in front of others and struggle with perfectionism or rigidity.)
- DBT-SUD (A subtype of DBT for adults and adolescents who have difficulty managing emotions andn substance use is a primary problem)
- Parent Skills (A psychoeducation class for parents seeking to support their adolescent or young adult children who have difficulty managing emotions.)
- Summer Boot Camp for Teens (14 to 18 year olds) Summer is a great time to shape-up skillful behavior and cope ahead for a new school year! ADBTA is offering 4 week DBT Skills Boot Camps for adolescents (14 to 17) who are home from summer and would benefit from a "skills refresher" and/or additional support.
  - Parents of enrolled teens will have the option of participating in a parent group that meets to review the skills their teens learned 1 hour per week.
- Adolescent (Middle School) Intensive Outpatient Program IOP clients will complete 18 group sessions over the course of 6 weeks and parents will complete 6 parent-skills and multi-family group sessions with their pre-teens over the course of 6 weeks.
Do you have a Psychiatrist?*

YesNo
Please list your Psychiatrist's name.*
Here is a list of our current group skills classes(Please choose a few schedule options, if your schedule allows. Your selection does not guarantee an immediate space in group, some of our offerings are full and on a waiting list. This will be discussed with you at scheduling)*

DBT Monday 6-7:30pm (Austin, in person) 11-14 year oldsDBT Monday 6-7:30pm (Austin, in person) 14-18 year oldsDBT Tuesday 6-7:30pm (Austin, in person) HIGH SCHOOLERS onlyDBT Wednesday 5-6:30pm (Virtual)DBT-Substance Use (Schedule TBD)RO-DBT Wednesday 4:30-6pm (Austin, in person)Parent/Family Skills Wednesday 12-1pm (Virtual)None of these work for me.Intensive Outpatient Program (Middle Schoolers only) (Austin, in person on Tuesdays, Wednesdays and Thursdays from 5:30-8:30 pm)Summer Boot Camp for Teens (Mon-Thu 10-12pm 7/5-8/7-4 weeks total)
Patient Name*

First NameLast Name
Your Name/Parent/Legal Guardian's Name*

First NameLast Name
Patient/Legal Guardian's Email*
If a minor, please enter guardian's email
Patient/Legal Guardian's Phone Number*
If a minor, please enter guardian's phone number
Patient's DOB*

MonthDayYear
How did you hear about us?*
Would you like to stay up to date with ADBTA and join our community email list?

Yes, keep me informed!No
Please list any specific concerns/challenges you'd like to work on and/or why you are interested in joining our program.

We are a cash practice and do not accept insurance, but can provide a superbill if you'd like to submit for out of network reimbursement through your insurance provider. We do require a credit card on file to secure the appointments. Be assured, we do not charge any fees until the day of service. We can take that info over the phone at time of scheduling or we can send you our payment authorization form through our secure Patient Portal.

Therapy services	Medication management services
Intake Fee: $150-$180 (one-time fee) Group orientation Fee: $100 Individual/Couples/Family/Parent coaching Fees: range from $150-$220 per 50 minute session Group skills Fees: $65 (adult), $80 (teen); weekly per 90 minute session	Intake Fee: $300 (one-time fee) Appointment Fees: range from $80-$300

Please verify that you are human*
Follow up completed:

EmailedLVMSpoke to via phoneText Message
Date Initial Follow Completed

MonthDayYear
Date
Reach Out Outcome and/or scheduling notes:
Should be Empty:

ADBTA Service Request Form

At our practice, we offer a variety of services to meet your needs. The first step to enrolling with us is to complete an initial intake assessment. Please fill out the form below and one of our practice managers will get back to you shortly to discuss scheduling an appointment.

If you have any issues with our request forms or our website, please email hello@austindbtassociates.com or call/text us at 512-902-3282.