DBT FORM DBT Follow up Info Patient’s First Name Birthdate Parent or Guardian’s first name (children and teens) Insurance BCBS United Healthcare/Optum Aetna/Meritain Tricare Medicare Kancare Sunflower Kancare Aetna Kancare United Trustmark/ProvidrsCare *Other Insurance/payment option if not listed above Please provide your Insurance ID for benefits check Please give a description of current symptoms and reason for seeking DBT therapy How many hospitalizations has the patient had in the last 2 years? Email Phone number Preferred contact method email phone How did you hear about DBT at The Monarch Center? Who are your current treatment providers including therapists and medication provider? What kind of mental health treatment have you had in the past and what was helpful/unhelful about it. DBT requires regular attendance including individual therapy sesesions and weekly group therapy sessions. Do you have any barriers that would prevent you from fully participating? Please acknowledge the following * DBT requires transfer of BOTH individual and group therapy to The Monarch Center Participants may return to their previous treatment providers once DBT is complete Filling out and submitting this form is not a guarantee of service and does not in any way guarantee that service will be provided by The Monarch Center or any of its affiliates. This form MUST NOT include any sensitive or personal information including (but not limited to): birthdate, medical history, social security number, home address, etc. By filling out and submitting this form you agree to be contacted by The Monarch Center or any of its affiliates regarding the options selected and/or described above. By checking the box below you also agree to our website Terms and Conditions. * By checking this box you agree to the Terms and Conditions listed above If you are human, leave this field blank. Submit
