DBT Program Application DBT Program Application Legal Name* First Last Preferred Name First Last Email Address* Phone Number*Sex* Male Female Gender Identity/Expression* Male Female Gender-expansive Fluid Pronouns He/him She/her They/them Participant Age*Participant Date of Birth* MM slash DD slash YYYY Custodian/Guardian Name (if applicable) First Last Custodian/Guardian Email Address Custodian/Guardian PhoneParticipant Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Maryland Medicaid Number (if applicable) Are you currently a client with FFCP?* Yes No Current Therapist First Last Current Therapist Phone NumberCurrent Therapist Email Current Symptoms*Do you (or child if client) engage in any of the following unsafe behaviors?*Self harmChronic suicidalitySuicide attemptsHair pullingSkin pickingSubstance useFood restriction or bingeing/purgingPhysical aggression towards othersOtherSelect any that apply.If other, please explain.Are you/your child willing to attend skills group every week as required by the DBT Program?* Yes No Do you have reliable transportation to attend weekly skills group at one of our locations? I have my own transporation. I do not have transportation. What is your preferred FFCP Office for weekly group?*ChooseColumbiaGreenbeltOlneyIf 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? Yes No If you are a parent of a client enrolling in the DBT program, do you yourself have Maryland Medicaid? Yes No By typing my name below, I understand that I intend/agree to continue to adhere to Families First Counseling & Psychiatry's attendance policy as well as the DBT Program's additional participation policy.* PhoneThis field is for validation purposes and should be left unchanged.
