Name *

First Name

Last Name

Professional Contact Number

Country

(###)

###

####

What clients do you currently intake? *

Please select any and all therapy provided. *adherence must include the stipulations provided by this site as well as full training

DBT Informed Therapy

DBT - Individual Adherent*

DBT Skills Informed Group

DBT Skills Group Adherent*

DBT-C Skills Groups*

DBT-S Skills Groups*

DBT Family Groups

DBT Family Therapy

DBT Couples Therapy

RO DBT Informed Therapy

RO DBT - Individual*

RO DBT Informed Skills Group

RO DBT Skills Group Adherent*

DBT Multicultural Groups

DBT Adherence *

DBT Adherence includes regular use of the following. Please select which ones you require and reinforce as a part of therapy.

Diary Cards

Individual Targets

Chain Analysis

Behavioral Principles

Skills Coaching Availability

Are your skills group co-led? *

Yes

No

N/A

Do you accept sliding scale? *

Yes

No

Do you accept insurance? *

No

AETNA

CIGNA

Blue Cross Blue Shield

United Healthcare

Anthem

Kaiser Permanente

Medicare

Other

DBT Professional Experience *

DBT - Individual (use of diary cards, chain analysis, reinforcement principles, skills coaching)

DBT Skills Group (co led)

DBT-C

DBT-S

DBT for Adolescents

Radically Open (RO) DBT - Individual

RO DBT Skills Group

DBT-PE

Parent Coaching

DBT with Couples/Families

Settings Where Practiced *

Please list all settings where you have practiced DBT for at least 3 months.

Outpatient (Private Practice or Group Practice)

Day Treatment

Sober Living House

Residential Program

Other (please list below)

Number of years practicing DBT *

Less than 1

1-2 years

3-7 years

8+ years

15+ years

DBT Trainings Completed *

Please select the level of training completed.

Behavioral Tech DBT Intensive Training™

TICLLC Comprehensive Training

Behavioral Tech DBT Foundational Training™

Behavioral Tech Online DBT Training

Certified Dialectical Behavior Therapy Professional (CDBT) Training by Lane Pederson

Principle DBT: A Comprehensive and Accelerated DBT Training Course

Radically Open Dialectical Behavioral Therapy™

Other (please list below)

Additional Trainings Completed

Please check all trainings completed.

Behavioral Tech DBT Skills Addiction Videos

Dialectical Behavior Therapy: Treating the Eating Disordered Client with Multiple Problems

Intensive Training in the Dialectical Behavior Therapy Prolonged Exposure Protocol for PTSD

DBT Skills Training: The Essentials LEVEL 2

Dialectical Behavior Therapy for Children (DBT-C) Training for Experienced Clinicians

DBT Skills with Multi-Problem Adolescents

Dialectical Behavior Therapy Skills for Adolescents with Multiple Problems: Engaging Teens and Caregivers

Assessment, Management, and Treatment of Individuals at Risk for Suicide

Adapting your DBT Program for Substance Use Disorders – DBT-SUD

2-Day Workshop: Dialectical Behavior Therapy (DBT) Coping Skills for Every Client by Clerissa Cooper

Other (please list below)

Are you DBT Certified?

This is advanced training and supervision beyond foundational or intensive training. Please only select if you have completed the DBT Certification process and have documentation. If you are unsure, please reach out to DBTGA for clarity.

DBT - Linehan Board of Certification

Evergreen Certification Institute

Other (please list below)

Are you on a formal DBT consultation team? *

These meet at least monthly and follow the consultation team requirements which include consultation to the therapist and feedback.

Yes

No

Specializations:

Please select those where you have training and experience using DBT.

Adoption

Autism

Bipolar

Black Women

Children

CPTSD

Eating Disordered Behaviors

LGBTQ

Maternal health

Multicultural

Obsessive-Compulsive Disorder (OCD)

Perinatal Mood Disorders

PTSD

Refugee Status

Residential Experience

Suicidality

Self harm

Substance Abuse

Sexual Exploitation

Sexual Violence

Teens

Other