DBT Skills Group - Wait list/Interest Form
Thank you for your interest in our DBT Skills Group at Radical Healing. To help us maintain a list of interested folx, please complete the following form.  

PLEASE NOTE: Since this form is transmitted electronically, confidentiality cannot be guaranteed.
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First and last name *
Date of Form Completion *
Pronouns *
Race/Ethnicity *
Phone Number *
Do we have your consent to... *
How did you hear about us?
Do you have preference for meeting times?
In what meeting format are you interested in participating?
Would you like to be considered for financial assistance?  If so, what amount would you be able to pay for weekly sessions over 6 mos?
Are you currently working with a DBT therapist or any therapist?
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