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.
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