APPLICATION FOR WAKE KENDALL'S ADOLESCENT DBT PROGRAM

Thank you for your interest The Wake Kendall Group's Dialectical Behavior Therapy program. Please refer to our web site (www.wakekendall.com) for more information about our DBT program and intake procedure. It is here that you will also find the address to which you should mail this form. Once we receive your application, we will give you a call within a few days.

Name of Adolescent:

Names of Parent(s)

Phone numbers:

Email address:

Upon request, we can email you a brief summary of fees and financial policies. If a family member will be paying for your therapy, we encourage you to forward this information along to that person in advance of your intake appointment. Finally, in the interest of protecting your privacy to the greatest extent possible, we request that you refrain from communicating electronically beyond this initial exchange.

Referral Source:

Age:

Grade and School:

How is he/she doing in school?

What is he/she struggling with (generally speaking)?

 

 

 

Does he/she engage in self-harming behaviors (e.g. cutting, alcohol and drug use, binging, purging, restricted eating, promiscuity, unsafe sex)?

 

 

Does he/she think about suicide? Any gestures? Any attempts?

 

 

Has he/she ever participated in any day treatment and/or hospitalization programs?

 

 

Has he/she ever suffered from unusual perceptions, hallucinations, disordered thinking, delusions, and/or significant paranoia?

 

 

Current diagnoses (to the best of knowledge)?

 

 

Current medications:

 

Does your adolescent take his/her medications consistently?

 

Prescribing psychiatrist:

 

Has he/she been in therapy before? How have those treatments gone?

 

 

What strengths does your adolescent possess?