DBT Enrollment Form
CCC is providing an 8 week DBT skills group. This is not a drop-in support group but one that allows members to develop a trusting relationship with one another throughout the course while learning and practicing the skills central to a DBT group.
Client Name
*
First Name
Last Name
Name that you go by (if different)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth (you must be 18 by the time of the group to participate)
*
-
Month
-
Day
Year
Date
What are your pronouns?
*
Example: she/her, he/him, they/them, etc.
Do you have any physical, gender, or cultural identities that you would like us to be aware of?
You are enrolling in the Summer 2026 DBT group focused on Interpersonal Effectiveness Skills.
Have you been in a DBT, CBT, or Social Skills group before?
*
Yes
No
What type of group were you in? Was it at CCC?
What did you like about the group you were in? What did you wish was different?
A facilitator will contact you to discuss the possibility of joining the group. When is the best time for them to call? Check all that apply for a faster response.
Rows
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
between 9am - noon
Between noon - 3:00
Between 3:00 - 6:00
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The Group Dynamic
CCC strives to create a safe space for everyone, regardless of race, ethnicity, immigration status, age, gender, sexual orientation, religion or disability status. We expect you to have the highest level of respect for your fellow group members if you choose to participate in the group services.
How comfortable are you with people who have a different gender expression or culture than yours?
*
Not at all comfortable
1
2
3
4
Very comfortable
5
1 is Not at all comfortable, 5 is Very comfortable
How comfortable are you with people who are have different religious or political beliefs?
*
Not at all comfortable
1
2
3
4
Very Comfortable
5
1 is Not at all comfortable, 5 is Very Comfortable
How comfortable are you with people who have different feelings, opinions, lifestyles?
*
Not at all comfortable
1
2
3
4
Very Comfortable
5
1 is Not at all comfortable, 5 is Very Comfortable
If you chose anything other than a 5 for any of the questions above, please explain:
Commitment to Group
Attendance is very important for you to get the most out of the group experience, as well as allowing trust and safety to grow amongst group members. In this DBT group, you will be challenged to show up when you want to and also when you don't. We understand that illness sometimes causes us not to be able to attend and have some accommodations for those rare instances. Your facilitator will discuss these during the orientation at the beginning of each group.
The upcoming Interpersonal Effectiveness module meets on Mondays from 5:30-7:00pm. The group will run from July 13th- August 31st. Will you be able to commit to attending all 8 weeks (with the exception of illness or emergency)?
Yes
I am not sure yet.
The cost of the group is based on a sliding scale fee of $5-40 per session (your choice). At least 50% of the full 8-week payment is due after the first session. Will you be able to pay these fees?
*
Yes
No
I need to speak to a staff member about a special payment plan.
Telehealth/Intake information
We hope for this group to meet IN PERSON, but there is a possibility that this group with need to be held via telehealth if a public health emergency is declared. If so, you will be provided with a link to dial into with a phone or video conferencing. We ask that video be used when attending groups, however we recognize that this is not possible for everyone. You will also need to find a space that is confidential for your safety and the safety of other group members.
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Group Expectations
Why are you seeking DBT Group services?
*
What do you hope to gain as a result of receiving DBT Group services?
*
This group asks participants to practice new skills during session and during the week, how comfortable are you with that?
*
Not Comfortable
1
2
3
4
Very Comfortable
5
1 is Not Comfortable, 5 is Very Comfortable
This group asks participants to complete homework, how comfortable are you in committing to that?
*
Not Comfortable
1
2
3
4
Very Comfortable
5
1 is Not Comfortable, 5 is Very Comfortable
This group encourages participants to participate and share during group, how comfortable with that?
*
Not Comfortable
1
2
3
4
Very Comfortable
5
1 is Not Comfortable, 5 is Very Comfortable
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Legal and Mental Health History
Do you have an order of protection against you or against another person?
*
Yes
No
Other
Are you currently on probation/parole?
*
Yes
No
Other
Do you currently have an individual therapist?
*
Yes, at CCC
Yes, not with CCC
No, but I am interested in services
No
Have you had therapy before? How long ago?
*
What skills or strengths do you currently have for coping with stress and difficulties?
*
Do you feel you are currently safe?
*
Yes
No
Other
Have you ever been in a substance abuse program? If so, please list when and through what facility or program.
*
Have you ever been hospitalized for mental health reasons? If so, please list when and what you were admitted for. (this does not include ER visits)
*
Do you have thoughts of hurting yourself or hurting others?
*
No
Yes
Other
If you are having thoughts of hurting yourself or others, please contact Lane County Behavioral Health's 24/7 Crisis Line at 541-682-1001
Have YOU ever previously attempted to die by suicide? *If yes, explain and provide the year of the most recent attempt.
*
Have you had a family member or loved one attempt or die by suicide? *If yes, please provide additional information.
*
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Contact Consents
Does CCC have your consent to contact you through email regarding your appointments and forms to be completed?
*
Yes
No
Other
Does CCC have your consent to identify ourselves when we call and leave a message at the number provided?
*
Yes
No
Other
Does CCC have your consent to text you at the number provided regarding attendance, group alerts and scheduling?
*
Yes
No
Other
Please list any additional comments here.
Submit
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