DBT Groups Inquiry Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Age
Gender Identity (used for group placement)
To better understand your needs, please answer the following questions:
My relationships tend to be intense and rocky, what people may refer to as "rollercoaster" relationships.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
My emotions can change very quickly, intense episodes of sadness, irritability, and anxiety that may last a few hours at a time.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I am quick to become upset and slow to calm back down.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I find it hard to control my anger and the intensity is not always appropriate for the situation.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I am not sure of who I am as a person, what I believe in, or how I should be.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I engage in impulse-behaviors that may cause me harm, such as excessive spending, risky sexual behaviors, or substance misuse.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I have feelings of chronic emptiness.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I worry about abandonment, and may engage in frantic behaviors to avoid being abandoned.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
During periods of stress, I may experience paranoia (I worry others are talking about me, dislike me, or may want to cause me harm).
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I either currently, or have in the past, struggled with non-suicidal self injury.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
I either currently, or have in the past, struggled with suicidal ideation or an attempt to complete suicide.
Please Select
0 = Never
1 = Seldom (once a year)
2 = Occasionally (every few months)
3 = Often (once a month)
4 = Frequently (every other week or so)
5 = Regularly (daily)
Have you ever been hospitalized for these symptoms, participated in intensive-outpatient, or partial hospitalization?
Is there anything else you would like me to know?
Type a question
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