To submit a referral for clinical services at Portland DBT Institute, please fill out the secure electronic 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 referral 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 referral form!*
If you do not have an email address, or if you prefer not to include one for privacy reasons, please enter the following placeholder email address: firstname.lastname@example.org
If you use the placeholder email, a copy of the completed form will only be sent to PDBTI Intake 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.
If you prefer to PRINT and fill out a referral form by hand instead, please click HERE to download our printable referral form . When you’re done, please fax it to 503-231-8153, or mail it to Portland DBT Institute, Attn: Intake Dept, 5200 SW Macadam Ave, Suite 580, Portland, OR 97239.
FAQ:How long does it take to process my referral?
I'm having issues completing or submitting the electronic referral form, what do I do?
If you have any technical difficulties or questions while completing our electronic referral form, please reach out to our Intake Team at 503-290-3291 or email@example.com.
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 Referral Form and fax it to 503-231-8153, or mail it to Portland DBT Institute, Attn: Intake Dept, 5200 SW Macadam Ave, Suite 580, Portland, OR 97239.
Who should fill out a referral form, and who is allowed to 'sign' to submit it?
Tip: You can zoom in/out of the form, just click the + / – buttons in the bottom toolbar!