DBT Boot Camp Application - The Bethesda Group Psychological Services, LLC

Participant's Name *

Participant's Date of Birth *

Best Contact Email *

Best Contact Phone Number *

Participant's School and Grade (if applicable)

How did you hear about us?

Guardian's Name (if participant in under 18 years old)

Guardian's Email and Phone Number (if applicable)

Please provide name, phone number, and email for your Primary Therapist *

Has the applicant completed a DBT Skills Class in the past? *

Yes

No

Where did you take the class?

How long ago?

Was it part of an outpatient DBT program?

Yes

No

In order to participate in this program, clients must participate in each module at least one time. Please select the sessions below and note that the interpersonal effectiveness module is only offered one time.

Session I: Distress Tolerance (July 10-14, 8:30-10:30 am)

Session II: Emotion Regulation (July 17-21, 8:30-10:30 am)

Session III: Interpersonal Effectiveness (July 24-28, 8:30-10:30 am)

Session IV: Distress Tolerance (TENTATIVE August 7-11, 8:30-10:30 am)

Session V: Emotion Regulation (TENTATIVE August 13-18, 8:30-10:30 am)

*We know the summer is a busy time! If you have any scheduling conflicts or concerns, please contact us and we will do our best to meet your needs.

In order to reserve your spot, please pay a $100 deposit after you submit this application (deposit is refundable for the next 7 days after you submit your application).

I will send my deposit after I submit this form (You will arrive at the payment page after submitting this form.)

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