Ebright Client Application Form
The following questions are meant as a pre-screening tool to help us gain a better idea of whether or not our program might be a helpful fit for you. Once you submit this form, someone from Ebright will contact you to further discuss your responses and next steps.

PLEASE NOTE: This form is meant to be completed by the perspective client only.

The following questions will ask for some identifying information so we can contact you (i.e. your first name, last initial, and phone number). This data is securely stored in line with HIPAA and HITECH laws and will not be shared by The Ebright Collaborative LLC.
Sign in to Google to save your progress. Learn more
What is your name? (e.g. John B.) *
Please answer with your first name and last initial only.
What pronouns would you like us to use? (e.g. he/him, she/they, etc.) *
What is your phone number (XXX-XXX-XXXX)? *
This is so that we may call you regarding your results.
Can we text you at this number? *
We just want to make sure even though most people use cell phones and prefer texts over retrieving voicemails.
How old are you? *
This helps us better understand which DBT program you would be best suited for.
Are you applying for our Adult or Adolescent DBT program? *
This helps us better understand which DBT program you would be best suited for.
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Ebright Collaborative, LLC. Report Abuse