Essentia Health runs up to 12 DBT groups per week. To ensure all participants are supported and that our programs follow best practices for DBT program delivery, we ask all participants to complete the below form. The information you provide below remains confidential and strictly follow’s Essentia Health’s Privacy Policy which is available at

Consent to our services needs to also be completed before anyone can commence service at Essentia Health. If there are any concerns about the below form you can speak to your individual clinician at the commencement of your session.

If you currently have a Psychologist or Counsellor please provide their details. If you do not have a therapist please type "No current therapist" If you do not have an individual therapist, Essentia Health has a range of individual therapists in the Bayside region of Melbourne, the Northern Beaches in Sydney, the Gold Coast in Queensland and online.
Please tick the most relevant response above.
If no additional needs or preference leave this blank or type "Nil"
If you have no preference please tick all days!
Click or drag a file to this area to upload.
Upload your mental health plan or referral from your GP or Psychiatrist if you have referral documents. If you have previously provided these details no need to send them through again.
To consent to attending our DBT Groups please tick ALL boxes above. Individuals who have not consented to treatment will be unable to join Essentia Health's DBT group program.