St. John's Cathedral Counselling Service DBT Skills Group Online Intake Form
Email address *
Date
MM
/
DD
/
YYYY
Full Name
Contact Phone Number
Age
Gender
Marital Status
Nationality/Ethnicity
Primary Language
Occupation
Have you experienced psychiatric/mental health issues?
Are you currently in therapy/counselling?
Do you have any thoughts of hurting yourself or others?
Are you currently involved in any legal proceedings?
Top three (3) concerns:
Additional information
A copy of your responses will be emailed to the address you provided.
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