top of page

Emotional Mastery DBT Skills Training Group

Registration Form
Purpose of This Form

This  form helps us gather the information needed to determine whether the A Life In Balance® Emotional Mastery DBT Skills Training Group is the right fit for you at this time.

 

You will be asked to provide basic information, answer brief readiness and intake questions, and confirm your understanding of the group format and expectations. Your responses are reviewed as part of a clinical screening process to support appropriate group placement and participant safety.  This form also includes the payment and billing agreement, which outlines how payment is collected and how enrollment is finalized.

 

Your responses are reviewed as part of a clinical screening process to support appropriate group placement and participant safety. Submission of this form authorizes payment to reserve your seat, pending clinical review. Enrollment is confirmed once clinical approval is complete.

 

This step ensures a thoughtful, ethical enrollment process and helps create a safe, supportive group environment for all participants.  This is not a full psychological assessment.

 

Completion of this form is required prior to enrollment confirmation.

SECTION 1: BASIC INFORMATION

SECTION 2: CURRENT THERAPY & SUPPORT

Are you currently engaged in individual therapy?
Yes
No

If yes:

If no:

Are you open to referrals or coordination of care if needed?
Yes
No

SECTION 3: REASON FOR INTEREST IN DBT SKILLS TRAINING

Which areas are you hoping to improve through this program? (Check all that apply)

SECTION 4: GROUP READINESS & STABILITY SCREENING

Please answer honestly. These questions help determine readiness and safety for a group-based skills program.

Are you currently experiencing a mental health crisis that requires immediate or intensive support?
Yes
No
In the past 30 days, have you experienced: (Check all that apply)
If you answered yes to any of the above, are you currently receiving appropriate clinical support?
Yes
No
Not applicable
How would you describe your current emotional stability?
Generally stable, with manageable challenges
Some instability, but I can function day-to-day
Frequently overwhelmed or emotionally dysregulated

SECTION 5: SAFETY & LEVEL OF CARE SCREENING

Do you feel able to participate safely in a group setting without requiring crisis intervention during sessions?
Yes
No
Are you able to commit to attending weekly 2.5-hour sessions for 24 consecutive weeks?
Yes
No
Do you have a reliable support system outside of this group (e.g., therapist, trusted person, support resources)?
Yes
No
Somewhat

SECTION 6: GROUP FORMAT ACKNOWLEDGMENT

Please confirm your understanding by checking each statement:

SECTION 7: TRACK SELECTION CONFIRMAT

Which support track have you selected?
DBT Skills Core Track
DBT Skills Continuity Track
DBT Skills Intensive Track

(Track selection reflects level of support, not severity. All tracks include the same DBT curriculum.)

SECTION 8: ADDITIONAL CLINICAL INFORMATION (OPTIONAL)

SECTION 9: PAYMENT & BILLING AGREEMENT

Please read and acknowledge the following:

SECTION 10: ACKNOWLEDGMENT & CONSENT

Please read and acknowledge the following:
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year
bottom of page