The Wake • Kendall Group PLLC
Psychological & Educational Services

APPLICATION FOR WAKE KENDALL'S ADULT DBT PROGRAM

Thank you for your interest The Wake Kendall Group's Dialectical Behavior Therapy program. Please refer to the DBT section of our website 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 Applicant:

Phone number(s) where you can be reached:

Age:

How did you learn about our program?

Educational level:

Briefly describe your weekly commitments (e.g. full- or part-time work, volunteer work, classes, family/friend obligations, hobbies, etc…).

Briefly describe what you are struggling with and/or the goals that you want to pursue with the help of our DBT program.

Briefly describe any self-harming behaviors you have engaged in during the past year.

Suicide Ideation: Within the last year, I have thought about killing myself…

Never / Sometimes / A lot

 

 

 

Suicide Gestures/Attempts: Within the last year, I have taken steps to kill myself…

Never / Sometimes / A lot

 

Have you ever participated in any day treatment and/or hospitalization programs for mental health issues? If so, please give the date(s) and reasons for intensive treatment.

 

Have you ever suffered from unusual perceptions, hallucinations, disordered thinking, delusions, and/or significant paranoia? If so, please describe briefly.

 

 

Current diagnoses (to the best of your knowledge):

Current medications:

What is the frequency with which you take your prescribed medications?

All of the time / Sometimes / Never

Explain, if needed:

 

Briefly describe your current professional support network (doctors, psychiatrists, psychologists, therapists, support groups, etc…)

 

Please give us a sense of your schedule and availability. Note that none of our therapists works on weekends. Some therapists offer early morning and/or early evening appointments.

Circle and/or rank times when you could come in for group skills training:

Tuesday AM (9:30-11:15) / Thursday PM (5:30-7:15) / Friday PM (12:00-1:45)

Describe your availability to come in for individual therapy: