DBT Outside Therapy Form

  • DBT Outside Therapy Form
    NYC PSYCHOLOGY INC., PC
    Manhattan | Brooklyn | Rockland County | Great Neck
    646-837-5557 | info@centerforanxiety.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


  • 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, case management, coaching, etc.). I understand that I will not receive any individual therapy or between-session support from NYC Psychology, PC, and that I will not receive any other services aside from a weekly DBT Skills group. I understand that I may choose to seek individual therapy as well as the above services from NYC Psychology, PC at a later point, in which case I will contact the office to make appropriate arrangements.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY