PDBTI Electronic Interest Form

To submit a request for clinical services at Portland DBT Institute, please fill out the secure electronic Interest Form below.

After you finish and “sign” to submit, you will have the option to immediately download a copy for your records. You will also be asked to enter an email address where you would like a confirmation email to be sent, which will include a link to access and re-download the completed form (up to 30 days). *Make sure to only enter an email address if you are okay with the account users potentially accessing your completed PDBTI interest form!*

If you do not have an email address, or if you prefer not to include one for privacy reasons, enter the following placeholder email address: none@pdbti.org. If you use the placeholder email, a copy of the completed form will only be sent to PDBTI Intake Team staff for processing. You will still have the chance to download a copy of the form if you like before you navigate away from this page.

PRINTABLE FORM
If you prefer to PRINT and fill out by hand instead, please click HERE to download our printable Interest Form. When you’re done, please fax it to 503-231-8153, or mail it to Portland DBT Institute, Attn: Intake Dept, 5200 S. Macadam Ave, Suite 580, Portland, OR 97239.

Frequently Asked Questions

How long does it take to process my interest form?
We typically review referrals within 24-48 business hours. A member of our Intake Team will phone you within 5-10 business days to go over your referral information and discuss treatment options. If you have not received a call within 10 business days of your referral submission, please reach out to us for assistance. You can call our Intake Department at 503-290-3291.
I'm having issues completing or submitting the electronic interest form, what do I do?
Click HERE to see a visual guide with step-by-step instructions and tips on completing/submitting an interest form electronically. This guide can help answer most questions about the process of filling out and submitting our interest form via Adobe Sign software.
If you have any technical difficulties or questions while completing our electronic interest form, please reach out to our Intake Team at 503-290-3291 or referral@pdbti.org.
Tips to keep in mind: Try re-submitting the form using a different web browser (e.g. Google Chrome or Mozilla Firefox). It’s also recommended to use a PC rather than a mobile device (though most mobile devices should be compatible). If you’re still having difficulties, you can instead fill out a printable Interest Form and fax it to 503-231-8153, or mail it to Portland DBT Institute, Attn: Intake Dept, 5200 S. Macadam Ave, Suite 580, Portland, OR 97239.
Who should fill out an interest form, and who is allowed to 'sign' to submit it?
We accept self-referrals as well as referrals from family, friends, clinical providers, or other folks involved in a person’s coordination of care. The form “signer” does not need to be the person being referred for services or a legal guardian, and their signature is not considered legally binding – it is simply required in order to submit the form for processing.

Tip: You can zoom in/out of the form, just click the + / – buttons in the bottom toolbar!