DBT Outside Therapy Form

DBT Outside Therapy Form
NYC PSYCHOLOGY INC., PC
Manhattan | Brooklyn | Rockland County | Great Neck
646-837-5557 | [email protected]

THIS FORM IS TO BE COMPLETED BY ALL DBT SKILLS GROUP PATIENTS WHO ARE RECEIVING INDIVIDUAL THERAPY FROM OUTSIDE OF OUR PRACTICE.

NYC Psychology, PC has my authorization to provide a copy of this document to my therapist and also to communicate in any way that might be beneficial to my treatment. I understand that full-service DBT typically involves DBT skills groups, DBT-focused individual therapy, plus between-session support (crisis management, coaching, etc.). I understand that I will not receive individual therapy, crisis management, or coaching from NYC Psychology, PC. I understand that I may choose to seek individual therapy as well as the above services from NYC Psychology, PC in which case I will contact the office to make appropriate arrangements.

The following person will be providing me with individual therapy:

ALL FIELDS MUST BE COMPLETED IN FULL

Name of Therapist:*

Email:*

Address:*

Phone number:*

NYC Psychology, PC has my authorization to provide a copy of this document to my therapist and also to communicate in any way that might be beneficial to my treatment. I understand that full-service DBT typically involves DBT skills groups, DBT-focused individual therapy, plus between-session support (crisis management, coaching, etc.). I understand that I will not receive individual therapy, crisis management, or coaching from NYC Psychology, PC. I understand that I may choose to seek individual therapy as well as the above services from NYC Psychology, PC in which case I will contact the office to make appropriate arrangements.

Patient Name:*

Date of Birth:*

Signature*

Today's Date:*

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