Maine DBT Center Application Form
After you have submitted this form, your name will be added to our waiting list and you will receive a confirmation notice. When your name comes up, you will be contacted by the next available clinician who will make an appointment for an assessment to determine your eligibility.
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Email *
Name *
Date of Birth *
Address
*
Phone number
*
Name of insurance
*
Scheduling needs for individual sessions
*
A copy of your responses will be emailed to the address you provided.
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