DBT Canberra Expressions of Interest form 2023

Expression of Interest in DBT Canberra's Skills program

Welcome to the DBT Canberra expressions of interest questionnaire. Please note: filling in this form does not guarantee you will be offered a place in the program but it does give us important information about who you are and your suitability to participate. PLEASE NOTE OUR PROGRAM IS FOR ADULTS so you must be over 18yrs old to apply. Please fill in as many fields as honestly as possible so we can accurately get to know you. It is best if you fill in the form for yourself. Please let us know if the form is filled on behalf of another person.

Prior to commencement in the DBT program, potential clients will need to move through the following pre-commitment phases:

Step 1. Fill in this questionnaire to provide your information

Step 2. If a space becomes available you may be contacted by a member of the team for a chat and to set up an assessment.

Step 3. The assessment will be conducted over the phone or person and you will then be considered for the next available space.

Step 4. Clients who are suited to the program meet their individual therapist who will help them understand the DBT program and ensure the client is prepared for the work ahead. This stage involves addressing any barriers that would make undertaking the program unworkable and involves a minimum of four sessions.

Step 5. Clients (in collaboration with their therapist) then decide whether to commit to the program for the 32 weeks.

We have seen DBT assist countless people to make healthy and significant changes in their lives and we are excited about the possibility of working with you!

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* 1. Contact Information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Can messages be left?

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* 3. Which of the following options most closely aligns with your gender?

Woman

Man

Non-binary

Transgender

Intersex

A gender not listed here

Prefer not to answer

preferred pronoun (please specify)

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* 4. Emergency Contact

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Date of Birth

Please list DOB - DD/MM/YYYY

Date

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* 6. Are you over 18 years old?

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* 7. How did you find out about DBT: (referred by GP or psychiatrist?) (Also: what do you know about DBT?)

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* 8. Do you understand that you will be required to fully participate in this intensive form of therapy for at least 32 weeks? Including attending weekly group skills training, weekly individual therapy, phone coaching and completing homework tasks and that you will need to cease seeing your current therapist?

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* 9. What are you hoping to get out or DBT? (presenting problems, expectations and general goals)

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* 10. What previous treatment have you had, and what was your experience?

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* 11. Are you currently seeing someone for therapy or counselling?

Yes

Other (please specify)

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* 12. If yes, are you willing to give up that therapist for the duration of the program?

Yes

Not applicable

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* 13. Diagnosis/ Problem Behaviours: Have you been given a mental health diagnosis?

If yes, what:

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* 14. Have you ever received treatment for Para-suicidal acts/ suicide attempts:

(Please list types of self harm engaged in and approximate number of episodes in the last 12 months and severity (including emergency, Hospital admission)

What do you see as your "problem behaviours"?

What types of self harm (if any) have you engaged in?

Please list any suicide attempts/ para suicide attempts including what happened afterwards

Do you suffer from suicidal ideation? If so how often?

when were you last hospitalised for psychosocial issues?

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* 15. Do you or have you ever experienced:

1) Emotion Dysregulation (inappropriate anger, instability of mood). please describe

2) Interpersonal Dysregulation (unstable and intense relationships, frantic avoidance of abandonment).please describe

3) Self- Dysregulation (chronic emptiness, unstable self-image). please describe

4) Behavioural Dysregulation (impulsivity, self-destructive, INCLUDING Para-suicidal acts/ suicide attempts/ recurrent self-harm).please describe

5) Cognitive Dysregulation (transient psychotic symptoms and dissociation). please describe

6) Active PTSD symptoms. please describe

7) Are there any current psychotic symptoms?

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* 16. How have these behaviours affected your life? What have been the costs?

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* 17. When was your last hospital admission? Was it voluntary or not?

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* 18. How is your life currently structured? – school, work etc?

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* 19. What are your current living arrangements? (living with parents or partner, supportive environment or invalidating, or traumatic?)

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* 20. Currently what are your supports? ( Services, therapy, family, friends)

formal supports

informal supports

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* 21. Providing Information - Do you need an overview of DBT/ basic info on DBT (if so you may like to visit the DBT Canberra website)

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* 22. Given the costs of comprehensive treatment will you be able to afford to pay:

Skills group: $2300 + for 6 months and the fees of your individual therapist negotiated with them (between $160 - $260 per hour for approximately 32 Weeks)

Yes

Other (please specify)

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* 23. Basic Commitment:

Can you attend individual therapy for 7 months?

Other (please specify)

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* 24. Can you attend skills group on a weekly basis?

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* 25. Are you going on holidays in 2023/ 2024?

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* 26. Do you understand that it will be challenging at times, and are you still able to give your best?

Yes

Other (please specify)

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* 27. Are there any barriers to doing DBT you can think of?

any serious medical conditions that might make it difficult to meet commitment?

Will drug and/or alcohol use be a barrier? if so are you willing to not use drugs/ alcohol on the days of therapy and skills group?

Are you currently in crisis without support

Are you willing to do your best not to use self harming as you acquire new skills?

would another less intensive & costly therapy work for you at this time?

Anything else that may be a barrier?

DBT Canberra Expressions of Interest form 2023

Expression of Interest in DBT Canberra's Skills program

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* 1. Contact Information:

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* 2. Can messages be left?

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* 3. Which of the following options most closely aligns with your gender?

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* 4. Emergency Contact

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* 5. Date of Birth

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* 6. Are you over 18 years old?

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* 7. How did you find out about DBT: (referred by GP or psychiatrist?) (Also: what do you know about DBT?)

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* 9. What are you hoping to get out or DBT? (presenting problems, expectations and general goals)

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* 10. What previous treatment have you had, and what was your experience?

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* 11. Are you currently seeing someone for therapy or counselling?

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* 12. If yes, are you willing to give up that therapist for the duration of the program?

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* 13. Diagnosis/ Problem Behaviours: Have you been given a mental health diagnosis?If yes, what:

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* 14. Have you ever received treatment for Para-suicidal acts/ suicide attempts:(Please list types of self harm engaged in and approximate number of episodes in the last 12 months and severity (including emergency, Hospital admission)

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* 15. Do you or have you ever experienced:

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* 16. How have these behaviours affected your life? What have been the costs?

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* 17. When was your last hospital admission? Was it voluntary or not?

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* 18. How is your life currently structured? – school, work etc?

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* 19. What are your current living arrangements? (living with parents or partner, supportive environment or invalidating, or traumatic?)

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* 20. Currently what are your supports? ( Services, therapy, family, friends)

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* 21. Providing Information - Do you need an overview of DBT/ basic info on DBT (if so you may like to visit the DBT Canberra website)

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* 22. Given the costs of comprehensive treatment will you be able to afford to pay:Skills group: $2300 + for 6 months and the fees of your individual therapist negotiated with them (between $160 - $260 per hour for approximately 32 Weeks)

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* 23. Basic Commitment:Can you attend individual therapy for 7 months?

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* 24. Can you attend skills group on a weekly basis?

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* 25. Are you going on holidays in 2023/ 2024?

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* 26. Do you understand that it will be challenging at times, and are you still able to give your best?

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* 27. Are there any barriers to doing DBT you can think of?

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* 28. Is there anything else we should know about you?

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* 29. Did you fill out this form on behalf of another person? If so please state why?

* 13. Diagnosis/ Problem Behaviours: Have you been given a mental health diagnosis?

If yes, what:

* 14. Have you ever received treatment for Para-suicidal acts/ suicide attempts:

(Please list types of self harm engaged in and approximate number of episodes in the last 12 months and severity (including emergency, Hospital admission)

* 22. Given the costs of comprehensive treatment will you be able to afford to pay:

Skills group: $2300 + for 6 months and the fees of your individual therapist negotiated with them (between $160 - $260 per hour for approximately 32 Weeks)

* 23. Basic Commitment:

Can you attend individual therapy for 7 months?