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Clinical & Psychosocial Questionnaire

A Life In Balance DBT Skills Training Group

Format: Virtual Group Skills Training

Duration: 24 Weeks (unless otherwise specified)


This questionnaire gathers additional clinical history and psychosocial information needed for group placement, safety, and individualized care and support for the DBT Skills Training Group. This questionnaire is not a diagnostic assessment and does not replace individual therapy.


Please respond honestly and thoughtfully.

  1. Current Clinical Support

Are you currently engaged in individual therapy?
Yes
No

Note: Concurrent individual therapy is required for participation in the DBT Skills Training Group.

Are you currently prescribed or taking psychiatric medication?
Yes
No
Prefer not to answer

  1. DBT Skills Training Focus

Which areas are you primarily hoping to strengthen through DBT skills training? (Check all that apply)

  1. Emotional Regulation & Coping (Current Functioning)

Over the past 1–2 months, how often have you experienced the following?

Strong or overwhelming emotions
Rarely
Sometimes
Often
Very Often
Difficulty calming yourself once emotionally activated
Rarely
Sometimes
Often
Very Often
Impulsive reactions when distressed (e.g., saying or doing things you later regret)
Rarely
Sometimes
Often
Very Often
Avoidance, emotional shutdown, or emotional numbing
Rarely
Sometimes
Often
Very Often

  1. Safety & Risk Check

The following questions gather clinical context to help inform group facilitation, pacing, and support needs within the DBT skills group. Responses are used to enhance clinical awareness and support coordination of care, as appropriate.

Are you currently experiencing suicidal thoughts or urges?
Yes
No
Have you engaged in self-harm behaviors within the past 6 months?
Yes
No
Have you participated in a higher level of mental health care (PHP, IOP, residential treatment, or psychiatric hospitalization) within the past 6 months?
Yes
No

If you answer “Yes” to any of the above, additional screening or support planning may be required prior to group participation.

  1. Group Participation & Engagement

Please confirm your understanding by checking each statement:

  1. Substance Use (Clinical Context)

Are you able to attend DBT skills sessions sober and fully present?
Yes
No

  1. Additional Clinical & Psychosocial Information (Optional)

  1. Attestation

By submitting this questionnaire, I confirm that:


• The information provided is accurate to the best of my knowledge

• I understand this questionnaire supports clinical awareness and group facilitation

• I understand participation may be adjusted if additional clinical support or coordination of care is indicated

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