DBT Outside Therapy Form
NYC PSYCHOLOGY INC., PC
Manhattan | Brooklyn | Rockland County | Great Neck
646-837-5557 | firstname.lastname@example.org
THIS FORM IS TO BE COMPLETED BY ALL DBT SKILLS GROUP PATIENTS WHO ARE RECEIVING INDIVIDUAL THERAPY FROM OUTSIDE OF OUR PRACTICE.
I, the undersigned, understand that I am coming to NYC Psychology,PC only for a Dialectical-Behavioral Therapy (DBT) Skills group and that I will be seeking individual therapy outside of the practice.
The following person will be providing me with individual therapy:
ALL FIELDS MUST BE COMPLETED IN FULL