DBTeen Referral Form

DBTeen is a dialectical behaviour therapy (DBT) program for young people aged 14-18 who display difficulty regulating their emotions and behaviour. This program is completed with an adult living in the same residence as the young person.

Young people who are receiving hospital and community mental health services (e.g.: CAMHS, CMHT, CATT, hospital inpatient) are not eligible to participate and will need to be discharged prior to commencing.

For further information contact our Administration on 08 6555 7785 or visit our website:

If you are experiencing difficulty submitting this form please email us at admin@aresolution.com.au

Date of referral

About the referrer

Who has recommended or referred you to come to us?

First Name *

Last Name *

Organisation Name

Referrer Address

Street address

City

State

Postcode

Phone number

Email address

If other* please specify

I have permission from the young person to refer them to this service *

YES

I have permission from the parent(s)/guardian(s) to refer them to this service *

YES

The Young Person and the Adult nominated below understand the program is completed together *

YES

About the young person

First name *

Last name *

Date of birth *

Age *Age limit: 14 - 18

Gender *

Pronouns *

If other* please specify

Home address *

Street address *

City *

State *

Postcode *

Phone number *

Email Address *

Is the young person of Aboriginal or Torres Strait Islander descent? *

Yes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait IslanderNo

Country of birth *

Please note: our DBTeen program participation requires a reasonable level of written, read and spoken English.

Primary language spoken at home *

How well does the young person speak English? *

Very wellWellNot wellNot at all

About the adult participating with the young person

Please note: must be living in the same residence

First name *

Last name *

Phone number *

Email address *

Date of Birth *

Relationship to the young person *

ParentLegal GuardianOther*

Please note: our DBTeen program participation requires a reasonable level of written, read and spoken English.

Primary language spoken at home *

How well do you speak English? *

Very wellWellNot wellNot at all

Young persons presenting concerns

Does the young person have a GP Mental Health Care Plan? *

YesNoUnknown

Please outline current concerns *

Please outline any current formal/informal diagnoses below *

Is the young person having thoughts of suicide? *

YesNoUnknown

Does the young person have a disability? *

YesNoUnknown

Does the young person take any medication? If yes, please list below *

Additional comments *

GP Details

Doctor's name *

Practice name *

GP Practice Address *

Street address *

City *

State *

Postcode *

Phone number *

Email address

By signing below, you confirm that all of the information provided above is true and correct to the best of your knowledge

Signature *

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Date *

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