DBT Therapy Group Questionnaire

Thank you for your interest in the DBT Teen Resilience Therapy Group. This questionnaire is the first step in our screening process and helps us determine whether the group is an appropriate fit for your needs. As part of the screening process, you will: Complete questions about your experiences with stress, emotions, relationships, coping, and overall well-being. Complete two brief mental health screening measures (PHQ-A and GAD-7). Answer a few questions about your goals and safety. Review and sign the DBT Teen Resilience Group Therapy Participation Agreement, which explains important information about confidentiality, attendance, expectations, and participation in the group. Your responses will be reviewed by a licensed mental health professional as part of the screening process and will help guide our clinical recommendations. There are no right or wrong answers. Please answer each question honestly based on how things have been for you recently, rather than how you wish they were. Estimated time to complete: 15–20 minutes

First & Last Name

Grade

School

Date of Birth

Parent / Guardian Name(s)

Email Address

Preferred Pronouns

Gender

Mobile Phone Number

Section #1 - DBT Screening Questionnaire

For each item below, choose the number below that best reflects your current experience. Use the rating scale below: 0 = Never 1 = Rarely 2 = Sometimes 3 = Often 4 = Very Often 5 = Always

I have trouble noticing what I am feeling until my emotions become very strong. When I am stressed, I feel disconnected, checked out, or like I am on autopilot.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

When I am upset, it is hard for me to get through the moment without making things worse. When life feels overwhelming, I struggle to cope in healthy ways

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

My emotions feel intense or difficult to manage. Once I become upset, it takes me a long time to calm down.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

I have difficulty expressing what I need or how I feel. Conflict with friends, family members, or others can be difficult for me to manage.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

When I am upset, it can be difficult to understand another person’s point of view. Communication with parents, caregivers, or other important people in my life is difficult.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

I feel stressed or overwhelmed by school, relationships, family, or other responsibilities. I spend a lot of time worrying about things that are happening in my life.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

I feel misunderstood, left out, or disconnected from others. I often feel like I have to deal with my problems on my own.

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Very Often

5 = Always

Section #2 - General Anxiety Disorder (GAD-7)

Please check the box that best answers the following question - Over the past 2 weeks, how often have you bothered by the following problems?

Feeling nervous, anxious, or on edge?

Not at all

Several days

More than half the days

Nearly every day

Not being able to stop or control worrying?

Not at all

Several days

More than half the days

Nearly every day

Worrying too much about different things?

Not at all

Several days

More than half the days

Nearly every day

Trouble relaxing?

Not at all

Several days

More than half the days

Nearly every day

Being so restless that it's hard to sit still?

Not at all

Several days

More than half the days

Nearly every day

Becoming easily annoyed or irritable?

Not at all

Several days

More than half the days

Nearly every day

Feeling afraid as if something awful might happen?

Not at all

Several days

More than half the days

Nearly every day

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Section #3 - Patient Health Questionnaire (PHQ-9)

Please check the box that best answers the following question - Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy?

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating?

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down?

Not at all

Several days

More than half the days

Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all

Several days

More than half the days

Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual?

Not at all

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way?

Not at all

Several days

More than half the days

Nearly every day

Section #4 - Group Readiness

Use the following scale: 1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree

I am open to trying new ways of handling stress and emotions.

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I am willing to participate respectfully in a group setting.

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I am willing to attend group regularly and actively participate.

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

Have you participated in a DBT group or another counseling group before?

Yes

No

If yes, please describe your experience:

Section #5 - Safety and Clinical History Please check any of the following that apply to you now or in the past. If you check any of the items below, a clinician will ask additional questions to better understand your experiences.

Thoughts about hurting yourself

Self-harm (cutting, burning, hitting yourself, or other ways of intentionally hurting yourself)

Suicide attempt(s)

Psychiatric hospitalization(s)

Hearing, seeing, or experiencing things that other people do not seem to hear, see, or experience

Use of alcohol, vaping, marijuana, or other substances

None of the above

Section #6 - Goals & Expectations Which concerns would you like support with in this group? (Check all that apply.)

Stress or feeling overwhelmed

Anxiety or excessive worry

Big emotions that are difficult to manage

Difficulty coping with stress

Relationship or family conflicts

Difficulty expressing feelings or needs

School-related stress or problems

Feeling lonely, misunderstood, or disconnected from others

Other

If you answered other, please describe:

What would you like most to accomplish in this group?

What concerns do you have about participating in this therapy group?

Is there anything important you would like us to know before considering you for this group?

Section #7 - Group Therapy Participation Agreement

Please read each statement carefully. By checking each box, you acknowledge that you have read, understand, and agree to the statement.

Nature of the Group The DBT Teen Resilience Group is a therapist-led therapeutic group designed to help teens navigate stress, emotions, relationships, and life challenges through discussion, peer support, and DBT-informed strategies.

I understand that this is a therapy group, participation is voluntary, and specific outcomes cannot be guaranteed.

Benefits and Risks of Group Therapy Potential benefits include increased support, improved coping skills, enhanced communication, emotional awareness, and healthier relationships. Risks may include temporary emotional discomfort, disagreements among group members, or discussing difficult experiences.

I understand the potential benefits and risks of participating in group therapy.

Confidentiality Participants are expected to respect the privacy of others and keep information shared in group confidential. Although Compassionate Edge is committed to maintaining confidentiality, it cannot guarantee that other group members will do the same. Confidentiality may be limited when required by law or when there are concerns about safety, including risk of harm, suspected abuse or neglect, or the need for parent or guardian involvement.

I understand the limits of confidentiality in a group setting and agree to respect the privacy of other group members.

Attendance and Participation Expectations Regular attendance is expected to support treatment goals and group cohesion. Participants are encouraged to attend each session and notify facilitators if they are unable to attend.

I understand the attendance and participation expectations for this therapy group.

Group Expectations and Behavior Participants are expected to treat others with respect and contribute to a safe, supportive group environment. Behaviors that jeopardize the safety of others or significantly interfere with the group may result in additional intervention, parent notification, temporary suspension, referral to a higher level of care, or discontinuation from the group.

I understand the behavioral expectations and possible consequences for unsafe or disruptive behavior.

Electronic Devices Phones and other electronic devices should be silenced and used only when requested by the group facilitator or during an emergency.

I understand the expectations for electronic device use during group.

Parent/Guardian Communication Parents or guardians may be contacted regarding safety concerns, significant behavioral concerns, repeated absences, or when additional services or a higher level of care may be needed.

I understand the procedures for safety concerns, emergencies, and parent/guardian notification when necessary.

Removal from group Compassionate Edge reserves the right to temporarily suspend or discontinue participation when necessary to maintain safety and support treatment effectiveness.

I understand that Compassionate Edge may suspend or discontinue participation when necessary to maintain a safe and therapeutic group environment.

Parent Signature Statement

By typing my name above, I acknowledge that I have read and understand this Participation Agreement, reviewed each acknowledgment above, and give permission for my child to participate in the screening process and, if accepted, the DBT Teen Resilience Therapy Group.

Teen Signature Statement

By typing my name, I acknowledge that I have read and understand this Participation Agreement, have reviewed each acknowledgment above, and voluntarily consent to participate in the screening process and, if accepted, the DBT Teen Resilience Therapy Group.

Parent, please upload a copy of your photo ID (driver's license or other government-issued ID) and your current insurance card. This information is used to verify your identity, confirm your insurance benefits, and prepare for your initial assessment. You can add multiple files.

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