Forms

The following resources are to supplement electronically fillable forms sent out during the intake process and to provide additional ways to communicate with PDBTI staff.  Many of our forms can be completed on-line.  For forms which cannot be completed online, you can fax the forms to (503) 231-8153, mail the physical forms to our offices at 5200 S Macadam Ave, Suite 580, Portland, OR 97239, or scan/take a picture and upload the forms to our secure portal.

For questions about these forms, or to receive forms in other formats, please contact the PDBTI intake team at (503) 290-3291 or referral@pdbti.org.


Release of Information (ROI) Forms
ROI forms are required for release of medical records to families, outside medical providers, or other entities that may request your records.

Online Release of Information Form Printable Release of Information Form
Printable ROI Form for Emergency Contacts Filled Example: Release of Information Form

Consent Forms

General Informed Consent

Online General Informed Consent Form Printable General Informed Consent Form

Telehealth Informed Consent
Telehealth services are offered through Zoom, a HIPAA compliant telehealth platform.  The Telehealth Informed Consent Form outlines the benefits and risks of using telehealth.

Online Telehealth Informed Consent Form Printable Telehealth Informed Consent Form

Audio/Video Informed Consent Form
PDBTI values supervision as a tool to improve the quality of services and patient outcomes.  The Audio Video Consent Form allows your therapist to record sessions in order to more effectively work with their supervisor.  No-one outside of PDBTI will view or listen to these recordings unless you specifically authorize this, and all recordings are kept using strict security procedures in full compliance with HIPAA and relevant Oregon/Federal law.

Online Audio Video Consent Form Printable Audio Video Consent Form

Personal, Financial, and Insurance Forms
These forms are typically provided during the referral process in a format where you can digitally fill out and sign the forms.  Please contact the intake team if you did not receive the the digital signature version of these forms.  Copies linked below are for your own records, or to print and submit manually if desired.  Please note paperwork marked as “First Session” is required to be submitted before the first session with our clinic.

First Session Paperwork
*Client Rights Notices

*Note: The Client Rights addendum is for your records only, and does not need to be submitted back to PDBTI.

Additional First Session Paperwork for Specialty Programs

Teen and Family Additional Assessment DBT-S Additional Assessment Form

Additional First Session Paperwork for Enhanced Skills Training (EST) Programs

EST Informed Consent EST Provider Agreement
EST Provider Crisis Plan and Information

Financial Guarantor Forms
This paperwork is required for any client with a guarantor (a financially responsible party).  This typically applies if the client is 18 years or older and has designated another person (such as a parent or guardian) to be financially responsible for their account during treatment.  The guarantor and client will need to complete the packet below prior to starting treatment.   Please note that the Release of Information must name the guarantor and be signed by the client to allow our Billing Dept to communicate with the guarantor regarding billing/account matters.   For the Credit Card Authorization form, make sure to include a copy of the front and back of the credit card

Financial Guarantor Forms

Insurance Update Forms
Current Portland DBT Institute clients or guardians can use this form if there is a change to insurance information, such as adding a secondary or tertiary policy, a switch in insurance carriers or plans, or a change in any other details that may impact our ability to bill the insurance. Remember to send us a copy of the front and back of the new insurance ID card as soon as your receive it. You can upload scans, pictures, or electronic cards to our secure file portal. You may also fax to (503) 231-8153 or mail the hard copies to our office at 5200 S Macadam Ave, Suite 580, Portland, OR 97239.

Online Insurance Information Update Form Printable Insurance Information Update Form