Emotional Mastery DBT Skills Training Group

Registration Form

Purpose of This Form

This form helps us gather the information needed to determine whether the A Life In Balance® Emotional Mastery DBT Skills Training Group is the right fit for you at this time.

You will be asked to provide basic information, answer brief readiness and intake questions, and confirm your understanding of the group format and expectations. Your responses are reviewed as part of a clinical screening process to support appropriate group placement and participant safety. This form also includes the payment and billing agreement, which outlines how payment is collected and how enrollment is finalized.

Submission of this form authorizes payment to reserve your seat, pending clinical review. Enrollment is confirmed once clinical approval is complete. This step ensures a thoughtful, ethical enrollment process and helps create a safe, supportive group environment for all participants. This is not a full psychological assessment.

Completion of this form is required prior to enrollment confirmation.

Program Eligibility & Readiness Form

A Life In Balance DBT Skills Training Group

SECTION 1: BASIC INFORMATION

First name

Last name

Preferred Name (if different):

Birthday (you must be 18 or older to enroll)

Month

Day

Year

Phone

Time Zone:

Country/State of Residence: (used to confirm we are able to serve clients in your location)

SECTION 2: CURRENT THERAPY & SUPPORT

Ongoing individual therapy is required throughout this program.

Are you currently engaged in individual therapy?

Yes

If yes, provide therapist information below:

Name

Phone

Frequency of sessions:

Length of time in therapy:

I understand that to enroll and remain in the group I must be in individual therapy, and that I may not go more than 4 consecutive weeks without an individual session. Individual therapy is available on an as-needed basis through A Life In Balance, or referrals can be discussed.

If no:

Are you open to establishing individual therapy before the program begins?

Yes

Not Applicable

SECTION 3: REASON FOR INTEREST IN DBT SKILLS TRAINING

What motivated you to seek DBT Skills Training at this time?

Which areas are you hoping to improve through this program? (Check all that apply)

What are you hoping will be different by the end of the program?

SECTION 4: GROUP READINESS & STABILITY SCREENING

Please answer honestly. These questions help determine readiness and safety for a group-based skills program.

If you are in crisis right now, please don't wait for this review — call or text 988 (Suicide & Crisis Lifeline) or use emergency services.

Are you currently experiencing a mental health crisis that requires immediate or intensive support?

Yes

In the past 30 days, have you experienced: (Check all that apply)

If you answered yes to any of the above, are you currently receiving appropriate clinical support?

Yes

Not applicable

How would you describe your current emotional stability?

Generally stable, with manageable challenges

Some instability, but I can function day-to-day

Frequently overwhelmed or emotionally dysregulated

SECTION 5: SAFETY & LEVEL OF CARE SCREENING

Do you feel able to participate safely in a group setting without requiring crisis intervention during sessions?

Yes

Are you able to commit to attending weekly 2.5-hour sessions for 24 consecutive weeks?

Yes

Do you have a reliable support system outside of this group (e.g., therapist, trusted person, support resources)?

Yes

Somewhat

SECTION 6: GROUP SELECTION

Which group are you applying to join?

DBT Skills Group (general) — core DBT skills through structured instruction, discussion, and practice.

BPD-Focused DBT Skills Group — the same skills taught through a guided case study on film; requires a documented BPD diagnosis.

If applying to the BPD-Focused group:

I have a documented diagnosis of Borderline Personality Disorder.

Diagnosing provider (name/role), if known:

I understand I may be asked to provide documentation of this diagnosis as part of clinical review.

I understand the BPD-Focused group teaches DBT skills through a guided case-study format that includes film clips portraying realistic experiences connected to BPD. Some scenes touch on heavier themes — which may include substance use, self-harm, and trauma — presented in a structured, supported way. I understand I can step out or debrief with the facilitator if needed.

SECTION 7: GROUP FORMAT ACKNOWLEDGMENT

Please confirm your understanding by checking each statement:

I understand this is a DBT Skills Training Group, not individual therapy.

I understand this is not comprehensive DBT.

I understand the group focuses on skills learning and practice, not trauma processing or crisis management.

I understand camera-on participation is required.

I understand consistent attendance is expected and skills build week to week.

I understand I must be concurrently enrolled in individual therapy during the program.

SECTION 8: TRACK SELECTION CONFIRMATION

Which support track have you selected?

DBT Skills Core Track — $125 per 2.5-hour session, pay as you go

DBT Skills Continuity Track — $525/month

DBT Skills Intensive Track — $3,600 paid in full

(Track selection reflects level of support, not severity. All payment tracks include the same sessions and curriculum for the group you selected above.)

SECTION 9: ADDITIONAL CLINICAL INFORMATION (OPTIONAL)

Is there anything you believe would be helpful for the therapist to know when reviewing your enrollment?

SECTION 10: PAYMENT & BILLING AGREEMENT

Please read and acknowledge the following:

I understand that enrollment is not confirmed until clinical review is completed and approved.

I understand that if I am not approved following clinical review, or I do not meet eligibility requirements, my initial payment will be refunded in full.

I understand the fees for the track I selected above and authorize the initial payment to reserve my seat.

I understand that once enrollment is confirmed, billing continues regardless of attendance, including missed sessions.

I understand that recurring billing (if applicable) begins one full billing cycle after the first session.

I understand that A Life In Balance is a private-pay practice and does not bill insurance directly; a superbill may be provided for possible out-of-network reimbursement, which is not guaranteed.

SECTION 11: ACKNOWLEDGMENT & CONSENT

Please read and acknowledge the following:

I understand that this group is not designed for crisis care or emergency support.

I understand that this form supports clinical review and enrollment determination.

I agree to notify my therapist (and the facilitator) if my level of care needs change during the program.

I understand I am responsible for seeking appropriate emergency or crisis services if needed.

I confirm that the information provided is accurate to the best of my knowledge.

Name

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year