Asheville DBT & Trauma | SimplePractice

Your info

First name

Last name

Phone

Date of birth

Gender

What is the client's preferred name, or name they go by?

If you are filling out this form for a minor, please put the name of the legal guardian here.

If you are filling out this form for a minor, please tell us what school district you are in:

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Client Preferences

Preferred appointment times

We make an effort to accommodate preferred times, but please note that this is not always possible.

Morning Afternoon Evening

Preferred clinician

Select a clinician from the list

Which service(s) are you interested in?

Individual Therapy Group Therapy Both Individual and Group Therapy

Which session-type would you prefer?

In-Person Virtual No Preference

Billing & Payment

What is your preferred payment?

BCBS Aetna Private Pay Low-Fee with an Intern

Reason for care

Have you had any recent psychiatric hospitalizations, or had a suicide attempt in the past 6 months?

If yes, please let us know if you have been to or are currently in an IOP or PHP

Limited to 600 characters

Do you have suicidal thoughts or engage in self-harm? This will help us determine a therapist with specialized training in this, if so.

Yes No

Have you been in DBT groups or therapy before? If so, where and when?

Limited to 600 characters

Please tell us briefly what is going on and what you would like help with the most.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.