DBT-C Class Registration

DBT-C Multi Family Group Registration Form

New participants are required to attend a 50 minute pre-registration intake assessment with one of our providers prior to attending a class. If you have attended a previous module at our practice, you do not have to complete the intake assessment.
Class Options:*

DBT-C Multi Family Group (8wks): Parent(s) & Child
Class Calc
Add-on Calc
Does the participant have a therapist with Peachtree DBT?*
Who is your current primary Peachtree DBT therapist?*
Remember that participants are required to be seeing an individual therapist at least once every other week.
Who is Your Current Primary Therapist? *
Remember that participants are required to be seeing an individual therapist at least once every other week.
Is the participant currently enrolled in a Skills Class module, or has the participant recently attended a class module within the previous six months at Peachtree DBT?*
A pre-registration intake assessment is required. Please continue in order to submit a request.

DBT Skills Class: Client Release of Information
Participant's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Outside Therapist's Email Address*
The above email address will be used to automatically send your provider the outside provider form for them to complete. If their email is unavailable, you may download and provide them a PDF copy of the outside provider form.
Outside Therapist's Phone Number*
Please enter a valid phone number.
I authorize full communication and the release of any pertinent medical information between my therapist and Peachtree DBT/Peachtree Psychiatric Professionals. I understand I will not be eligible to participate in the Peachtree DBT Skills Training Program unless I regularly attend individual therapy sessions on an on-going basis. There will be a case management fee for all clients with an external primary therapist.
Patient/Guardian's E-Signature *

Clear
Guardian's E-Signature

Clear
After submitting this form to our office, the skills training instructor will contact your primary therapist to establish an open line of communication in order to discuss the client's diagnosis and any important clinical information.

Terms and Conditions
- I agree and understand that participants who are new to the program are required to complete a DBT orientation intake session prior to the start of class. For participants who have previously attended a Peachtree DBT class module, the DBT orientation intake session is not required.
- I agree and understand that full registration and payment is required to attend class and my registration will be considered incomplete until payment is received.
- I agree and understand that if I miss any or drop out of class for any reason, I will not be reimbursed.
- I agree and understand that payment and registration confirmation emails will be sent to the primary email address submitted. Such emails may contain the health information that I submitted.
I have read and agree to the above terms and conditions

Total*

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DBT-C Multi Family Group Registration Form