DBT Centre of Vancouver referral form

IMPORTANT NOTE

Information collected in the online referral form will be sent directly to our secure clinic email (info@dbtvancouver.com).

Once we review the information provided, we will do our best to connect you with one of our available clinicians based on your preferences and availability for appointments. Please keep in mind that there might be a wait to see some clinicians or to begin some of our services.

Please be aware that while we aim to connect you with one of our clinicians/services, we cannot guarantee service provision.

The purpose of this referral form is to collect information only and does not establish a therapeutic relationship. By completing and submitting this form, you acknowledge that:

The information provided will be used solely for the intended purpose of referral.
No therapeutic relationship or services are implied by the completion of this form.
Confidentiality of the information provided will be maintained to the extent required by law and professional standards.

CONTACT INFORMATION

Who is completing this form?

Adult (self) Parent / partner / family of an adult Parent of a teen (13 - 17 y/o) Parent of a child (under 13 y/o)

Full name

Your name

Your email

Phone number

Can we leave a voicemail?

Yes No

Date of birth

Your phone number

Can we leave a voicemail?

Yes No

Name of person you are referring

What is your relationship to them?

Parent, partner/spouse, family, friend

Name of your child

Their date of birth

Do they know you are reaching out on their behalf?

Their phone number

Their email

Is there another parent/caregiver involved?

Yes No

If you would like us include them in email correspondence, add their name and email.

Psychological services are regulated by the province, as such, we are limited to providing services to people that reside and are physically in British Columbia at the time of the service. If a client is out of province during their session(s), alternate arrangements made need to be arranged. Please let us know if you are frequently out of the province.

Where do you live?

Where do they live?

CLINICAL INFORMATION

Were you referred for DBT services or was DBT was recommended by someone?

For eg., referred by counsellor/psychologist, psychiatrist, friend, family, etc.

Was DBT recommended for them or were they referred to DBT?

For eg., referred by counsellor/psychologist, psychiatrist, friend, family, etc.

What are some of the reasons you are seeking out services?

DBT is often recommended for people struggling with intense and painful emotions that are difficult to manage, self-harm, chronic suicidal ideation, substance abuse problems, past trauma, disordered eating.

What are some of the reasons DBT is recommended?

What are some of the reasons they are seeking DBT?

Are you currently seeing another therapist, counsellor, or psychologist on a regular basis?*

Yes, I would like to do the DBT group only.

Yes, and I would like to continue seeing them.

Yes, and I plan to stop seeing them once I start seeing a DBT therapist.

Other

Are they currently seeing another therapist, counsellor, or psychologist on a regular basis?*

Yes, they would like to do the DBT group only.

Yes, and they would like to continue seeing them.

Yes, and they plan to stop seeing them once I start seeing a DBT therapist.

Other

Is your child currently seeing another therapist, counsellor, or psychologist on a regular basis?*

Yes

Other

*Why are we asking about this? Mental health clinician generally look out for "overlapping services", which typically means seeing more than one individual therapist at a time. If you have an individual therapist already, our clinician may discuss different treatment options, such as pausing therapy with the current therapist or participating as a "group only" client.

How often are you seeing the therapist?

Once a week

Once a month

Scheduled on an as needed basis.

Other

Add details below.

How often are they seeing their therapist?

Once a week

Once a month

Scheduled on an as needed basis.

Other

Add details below.

Additional information you would like to share about your therapist:

Additional information you would like to share about their therapist:

Do you have any other mental health care professionals in your care?

For eg., psychiatrist, case manager, etc.

Do they have any other mental health care professionals in their care?

For eg., psychiatrist, case manager, etc.

Clients that see a mental health clinician on a regular basis may be eligible to join as a "group only" client. The DBT group skills program is not therapy (and does not replace individual therapy) as such all clients must be under the care of a psychologist, counsellor, or social worker) and see them at least once a month. All clients need to start with the intake assessment to ensure that the DBT group skills program would be appropriate. Group only clients are welcome to "transfer" their individual therapy services once a DBT clinician becomes available. Please let us know if this option might be of interest.

PREFERENCES AND AVAILABILITY

INDIVIDUAL THERAPY

Individual therapy is typically one hour once a week and scheduled as weekly standing appointments (ie., same time each week).

Individual therapy hours are limited to regular business hours, i.e., Monday – Thursday, 9am – 5pm. We do not have weekend or evening hours for individual therapy.

In-person or Zoom appointments are available for individual therapy sessions.

What days/times work better for you?

Monday afternoon

1pm - 5pm

Tuesdays

9am - 5pm

Wednesdays

9am - 5pm

Thursdays

9am - 5pm

All times/days work.

I'm flexible.

Other

Add details below.

Not applicable.

I have a therapist in the community and I would like to do "group only" services.

What days/times work better for them?

Monday afternoon

1pm - 5pm

Tuesdays

9am - 5pm

Wednesdays

9am - 5pm

Thursdays

9am - 5pm

All times/days work.

They are flexible.

Other

Add details below.

Not applicable.

They have a therapist in the community and would like to do "group only" services.

What days/times work better for them?

Monday afternoon

1pm - 5pm

Tuesdays

9am - 5pm

Wednesdays

9am - 5pm

Thursdays

9am - 5pm

All times/days work.

They are flexible.

Other

Add details below.

Are there times or days that DO NOT work for individual therapy?

Would you prefer in-person or Zoom sessions?

In-person only.

Zoom only.

Prefer in-person but will do Zoom.

Would they prefer in-person or Zoom sessions?

In-person only.

Zoom only.

Prefer in-person but will do Zoom.

Are there other factors you would like us to consider in connecting you with a clinician?

Are there other factors you or they would like us to consider in connecting them with a clinician?

Please note: we do not have any psychiatrists on staff; as such, we are not able to provide any advice related to medication or medication management. Unfortunately, we are not able to provide referrals to psychiatrists.

DBT SKILLS GROUP PROGRAM

The DBT skills group program is a 26-week course that teaches DBT related skills. The group is led by two of our clinicians and there are a maximum of 12 people in the group. DBT skills are taught in a class-like format and covers DBT skills such as:

managing attention (mindfulness module - 6 weeks total),
managing and coping with overwhelming emotions (emotion regulation module - 8 weeks),
building healthy relationships while maintaining self-respect (interpersonal effectiveness module - 6 weeks)
tolerating emotional distress without making matters worse (distress tolerance module - 6 weeks)

DBT skills groups are currently running online and are at the following times/days. Check all that work for your schedule:

Mondays 5:30 - 7:30pm (Zoom only)

Tuesdays 5:30 - 7:30pm (Zoom only)

Tuesdays 6pm - 8pm (Zoom only)

Thursdays 5:30pm - 7:30pm (Zoom only)

DBT skills groups are currently running online and are at the following times/days. Check all that work for their schedule:

Mondays 5:30 - 7:30pm (Zoom only)

Tuesdays 5:30 - 7:30pm (Zoom only)

Tuesdays 6pm - 8pm (Zoom only)

Thursdays 5:30pm - 7:30pm (Zoom only)

Additional details on availability for group.

BILLING AND PAYMENT INFORMATION

Our current fee schedule is available is here.

Our fees are not covered by MSP, WorkSafe BC, ICBC, Income Assistance but some of our services may be eligible for reimbursement by an insurance provider. Who will be paying for services?

I will be paying for services.

Loved one(s) will be paying for services.

Other

Additional details on billing and payment.

Do you have extended benefits through work or spouse? For eg., Manulife, Greenshield, Pacific Blue Cross

Yes

Not sure

Do they have extended benefits through work or spouse? For eg., Manulife, Greenshield, Pacific Blue Cross

Yes

Not sure

If you have extended benefits, how important is it that you see a clinician for whom you can get reimbursement? Some insurance providers will only cover certain types of clinicians. For example, some providers will cover psychologists, some won't. If we cannot connect you with a clinician you would like, we can add you to a wait list.

Very important

I only want to see a registered psychologist. I will wait until one becomes available.

Not important

I'm open to seeing any clinician.

Not applicable

I have a therapist already and will only be participating in the DBT skills group.

If you or they have extended benefits, how important is it that they see a clinician for whom they can get reimbursement? Some insurance providers will only cover certain types of clinicians. For example, some providers will cover psychologists, some won't. If we cannot connect you with a clinician you would like, we can add you to a wait list.

Very important

They only want to see a registered psychologist. They will wait until one becomes available.

Not important

They are open to seeing any clinician. The sooner the better.

Not applicable

They have a therapist already and will only be participating in the DBT skills group.

Additional details on extended benefits.

We have doctoral students that provide services at a lower fee ($125) per session. Do you prefer to see a student for financial reasons?

Yes - student only please.

We have doctoral students that provide services at a lower fee ($125) per session. Would they prefer to see a student for financial reasons?

Yes - student only please.

A brief note about wait times

There sometimes is a wait to get connected with services. The wait is generally going to be shorter when someone is open to seeing any type of clinician (ie, a psychologist, doctoral clinician, or doctoral student), at any time during the week, and via any modality (i.e., Zoom or in-person).

MISCELLANEOUS INFORMATION

Is there anything else you would like to add?

Your information will be encrypted.