Start your journey with OPAL DBT Ready to get started?Want to learn more? Program Application Program Application_Nov_24 Your Name First Name Last Name Email Phone (###) ### #### Referral Source Name of potential client First Name Last Name Age 5 or younger 12 or younger 18 or younger 25 or younger over 25 N/A Current Grade Level (if 18 or younger) kindergarten or lower elementary school (1st – 5th) middle school ( 6th – 8th) in high school completed high school Potential Client Email Potential Client Phone (###) ### #### Does the potential client have a therapist? Yes No If so, therapist phone and email: Treatment Requested DBT Skills Training ( client already has a therapist) Comprehensive DBT (individual DBT and Skills Training) Individual Therapy Dialectical Parenting Course unsure What brings you here? Thank you for your interest in treatment with OPAL DBT. We’ll do our best to respond within two business days. If not, please feel free to contact us at opal@opaldbt.com.
