FFCP DBT Program Client Application Form
Participant First Name *
Your answer
Participant Last Name *
Your answer
Participant Age *
Your answer
Custodian/Guardian Name (if applicable)
Your answer
Phone Number *
Your answer
Address *
Your answer
Maryland Medicaid Number (if applicable)
Your answer
Are you currently a client with FFCP? *
Current Therapist
Your answer
Current therapist phone number
Your answer
Current therapist email
Your answer
Current diagnosis and other pertinent symptoms *
Your answer
Do you (or child if client) engage in any of the following unsafe behaviors (select any that apply)
Are you/your child willing to attend skills group every week as required by DBT Program *
Do you have reliable transportation to attend weekly skills group at one of our offices or will you need a cab service? *
What is your preferred FFCP office for weekly group? *
If you are a parent of a client who is enrolling in the DBT program are you or another guardian/parent willing to attend parent group weekly for the duration of the program?
If you are a parent of a client enrolling in the DBT program, do you yourself have Maryland Medicaid?
By typing my name below, I understand that I intend/agree to continue to adhere to Families First Counseling and Psychiatry's attendance policy as well as the DBT Program additional participation policy. *
Your answer
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