Forms

Getting Started
In order to get you started with services with Portland DBT Institute we need a little information first. Filling out our Electronic Referral Form will get us all of the information that we need in order to add you to our wait list. Once we receive your referral we will contact you in 1-3 business days, review your referral, verify the information we received, answer any questions you have, and add you to our wait list. For more information about getting started at pdbti please visit our Getting Started page.

Electronic Referral Form
For clients who plan to participate in individual therapy and group therapy as well as our EST program.

Electronic Referral Form – Group Only
For clients who plan to attend a group that does not require individual therapy with Portland DBT Institute.

Printable Referral Form
If you would prefer to print a referral form to fill in by hand please use our printable referral form and return by mail or fax. We ask that you not return referral forms via email as this is not considered a secure form of transmission.


Required Personal, Financial, and Insurance Forms for All Clients
We are excited to have you starting services at the Portland DBT Institute! In order to maximize the amount of time you can speak to a therapist in the initial session, please bring the relevant paperwork below to the first session. 

First Session Paperwork
Once you have been scheduled for your first appointment with PDBTI, please print, fill out and sign your first session paperwork. Please bring the completed paperwork with you to your first appointment. If you cannot bring the paperwork to the first session, please plan on coming to the clinic thirty to forty-five minutes early in order to complete the intake paperwork.

Eating Disorder Intensive Out Patient First Session Paperwork
This client information form is for new clients who will be joining our ED IOP program. Please print, fill out and sign your first session paperwork and bring the completed paperwork with you to your first appointment. If you cannot bring the paperwork to the first session, please plan on coming to the clinic thirty to forty-five minutes early in order to complete the intake paperwork.


Additional Forms for Specialty Programs
These forms are required for clients who will be getting started in our DBT specialty programs.

Teen and Family Additional Assessment
DBT-S Additional Assessment Form
PME Additional Assessment Form


Enhanced Skills Training (EST) Forms
These forms are required for clients who will be getting started in our EST groups.

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.k.a. a financially responsible party).  Usually this applies if the client is 18 years or older and has designated another person (such as a parent, guardian, other responsible party) to be financially responsible for their account here at PDBTI. The guarantor and client will need to complete & submit the following forms prior to starting treatment: Guarantor Policy, Credit Card Authorization, and Release of Information.   Please note that the Release of Information (ROI) 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.  Complete forms can be delivered to our office in person, faxed (503-231-8153), mailed (5200 SW Macadam Ave, Suite 580, Portland, OR 97239), and uploaded to our secure file portal (visit this page: https://www.pdbti.org/secure-upload/).  

Financial Guarantor Forms


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. To grant permission to pdbti to release your medical records you must fill out sign and return an ROI form to PDBTI.

Release of Information Form
Release of Info Example