DBT-C (Parents Only) Skills Class Registration Form

DBT-C (Parents Only) Skills Class 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. The parents only DBT-C skills class is 12 weeks long and the cost is $960. Payment is due in full upon registration.
Parent Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Child Full Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
How did you hear about us?
Please review:

I agree and understand that parent class participants who are new to the program are required to complete an 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.
Please indicate that you have read and agree to the above.*

I have read and agree to the above terms and conditions.

Payment

DBT-C Parents Only Skills Class

$960.00 Quantity

Total

$0.00

Credit Card

Signature - Please sign below to confirm that the information provided is true and correct to the best of your knowledge.

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