Thank you for referring an individual you serve to Family Service & Guidance Center’s Dialectical Behavior Therapy (DBT) group!

We’re grateful for your trust and take this responsibility very seriously. FSGC is happy to make this proven therapeutic group available to teens in our community.

The goal of this page is to make the referral and admission process simple and efficient. The information and forms you provide will make it possible for the adolescent you are referring to undergo a significantly shortened admissions process at FSGC.

When the referral form is complete and all the necessary paperwork is uploaded, be sure to remember to press SUBMIT. Again, thank you for partnering with Family Service & Guidance Center!

Please complete the following:

Please work with the individual you serve and their family to complete the following four forms. Please note: On the Use & Disclosure forms, you only need to answer the highlighted questions/items.

Use & Disclosure Form- Insurance

Use & Disclosure Form – Parents

Use & Disclosure Form – Provider

Consent for Treatment Form

Once the forms are complete, please upload them at the bottom of the referral form.

Please send the following paperwork you already have on file for the adolescent you are referring. Simply upload it at the bottom of the referral form.

Admission Report
Diagnostic List
Medication List
SED Waiver Paperwork

DBT Group Referral Form

Referral for Dialectical Behavior Therapy (DBT)

"*" indicates required fields

Referrer First Name*

Referrer Last Name*

Name of Referrer's Practice or Organization (if applicable)

Referrer Phone*

Referrer Email*

Youth's Name*

Youth's Date of Birth*

Youth's Age*

Youth's Gender*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Primary Contact Phone*

Alternate Phone Number

Parent/Guardian Email*

Clinical reason for referral to DBT group?*

Has the youth exhibited any problematic sexualized behaviors?*

Yes

Has the referral been discussed with the family?*

Yes

Please convert completed referral forms to PDFs and upload them here.*

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Phone

This field is for validation purposes and should be left unchanged.

Mental Health Referral

Referral for Dialectical Behavior Therapy (DBT)

Thank you for referring an individual you serve to Family Service & Guidance Center’s Dialectical Behavior Therapy (DBT) group!

Please complete the following:

DBT Group Referral Form

Referral for Dialectical Behavior Therapy (DBT)

Address

Phone