SHCS DBT Group Screener

Is the DBT program right for me?

(This assessment is designed for ages 12+)
I am filling out this screener for:*
Is this screener for a new patient at Safe Harbor, or an existing patient?*
Select the state the patient resides in. (Note: Safe Harbor's DBT program is currently only available to Maryland or DC residents)*

MDDCVAOther
How did you hear about the DBT program?*

DBT Screener Questions
The following questions ask about patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to you. Your results will be calculated for you at the bottom of the assessment.

If you provide your contact information, one of our DBT coordinators can reach out to you to provide more information.

Please note that this assessment is not a substitute for a proper diagnosis from a health care professional.

DBT Screener Questions
Please fill out the following questions with or on behalf of your patient. These questions ask about patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to your patient. The results will be calculated at the bottom of the assessment.

If you provide your contact information, one of our DBT coordinators can reach out to the patient to provide more information. Please inform your patient that someone from our agency will be reaching out to them.

Please note that this assessment is not a substitute for a proper diagnosis from a health care professional.

DBT Screener Questions
Please fill out the following questions with or on behalf of your child. These questions ask about patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to your child. The results will be calculated at the bottom of the assessment.

If you provide your contact information, one of our DBT coordinators can reach out to you to provide more information.

Please note that this assessment is not a substitute for a proper diagnosis from a health care professional.

Screener Score
Total Score*
What your score means.....
- 0-22 The DBT program may not be a good fit for you
- 23-46 The DBT program may be ideal for you (please provide info below)
- 47-69 Further evaluation is needed to determine if appropriate (please provide info below)

Is it okay to contact you?

One of our DBT coordinators would love the opportunity to explain the DBT program to you and see if it may be a good fit. Please fill out your information below to find out more.

Is it okay to contact your patient?

Please fill out the following information below if our DBT coordinator can reach out to the patient directly. Our team will speak with them to determine if they are a good fit for the program. If so, they will be scheduled for a group. If groups are full, they will be placed on a waiting list and you will be notified. Please note that if your child is 18 or over, we will need to speak with them directly. If you are completing this screener for your child who is UNDER the age of 18 please provide the contact information of a parent/guardian and not the contact information of the child. If you are completing this screener for your child who is OVER the age of 18 please provide the contact information of the child.
Name of Referring Provider*

First NameLast Name
Referring Counselor`s Practice*

Safe Harbor Behavioral Care (MD)Safe Harbor Community ServicesSafe Harbor Behavioral Care of Northern VirginiaSafe Harbor Behavioral Care of ChesapeakeCedar RidgeOther

Is it okay to contact you?

Please note that if your child is 18 or over, we will need to speak with them directly. If you are completing this screener for your child who is UNDER the age of 18 please provide the contact information of a parent/guardian and not the contact information of the child. If you are completing this screener for your child who is OVER the age of 18 please provide the contact information of the child.

Important Safety Questions
Is the patient being referred currently struggling with any of the following areas?*

EatingAlcoholDrugsSpendingGamblingSex/PornographyOtherNot currently struggling with any of these areas
Has the patient being referred ever attempted to take their own life or engaged in self-injurious behavior?*
How many times has the patient been hospitalized in the last year due to a mental health related concern?*
Consent to Provide this Information to Safe Harbor Staff
I acknowledge and consent for my information to be sent to Safe Harbor
Status
Benefits
Should be Empty:

Is the DBT program right for me?