DBT Skills Group

1
What is the main area you are looking for support with?* This field is required.
Please select one of the following options
ADHD (strategies to manage)
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
Bipolar (Type I or II)
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Depression, sadness, or low mood
Dissociation
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Family conflict
Grief or loss
Life transitions/uncertainty
OCD-related symptoms
Parenting
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual dysfunction
Sexual or gender identity
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (multiple incident or ongoing)
Trauma (single-incident)
Work or school issues
2
What other areas are you also looking for support with?Skip if there are no other areas you are looking support with
ADHD (strategies to manage)
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
Bipolar (Type I or II)
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Depression, sadness, or low mood
Dissociation
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Family conflict
Grief or loss
Life transitions/uncertainty
OCD-related symptoms
Parenting
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual dysfunction
Sexual or gender identity
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (multiple incident or ongoing)
Trauma (single-incident)
Work or school issues
3
How long have you been dealing with these challenges?* This field is required.
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
4
How much are these issues impacting your day-to-day (mood, relationships, work, health)?* This field is required.
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
5
SF - What is the main area you are looking for support with?
ADHD (strategies to manage)
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
Bipolar (Type I or II)
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Depression, sadness, or low mood
Dissociation
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Family conflict
Grief or loss
Life transitions/uncertainty
OCD-related symptoms
Parenting
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual dysfunction
Sexual or gender identity
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (multiple incident or ongoing)
Trauma (single-incident)
Work or school issues
6
What other areas are you also looking for support with?Skip if not applicable
Please select one or more of the following options or skip if N/A
ADHD (strategies to manage)
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
Bipolar (Type I or II)
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Depression, sadness, or low mood
Dissociation
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Family conflict
Grief or loss
Life transitions/uncertainty
OCD-related symptoms
Parenting
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual dysfunction
Sexual or gender identity
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (multiple incident or ongoing)
Trauma (single-incident)
Work or school issues
7
Program available to participants 18 years or older* This field is required.Layla's partner therapists for this program are licensed in Alberta, British Columbia, Nova Scotia, and Ontario. Therefore, this program is available only to residents of those provinces at this time.
I am a resident of Alberta, British Columbia, Nova Scotia or Ontario and I am 18+ years old *
8
Layla is not a crisis service (For other crisis resources click here)* This field is required.As our forms are not monitored 24 hours a day or all days of the week, if you or someone you know is in crisis or at risk of serious harm towards yourself or others, call 911 or go to an emergency room.
I am not dealing with an immediate safety concern.
9
SF - How long have you been dealing with these challenges?
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
10
SF - How much are these issues impacting your day-to-day (mood, relationships, work, health)?
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
11
Have you received a psychological diagnosis from a qualified healthcare professional?Skip if not applicable
Please select one or more of the following options or skip if N/A
ADHD (strategies to manage)
Adjustment disorder
Agoraphobia
Anorexia Nervosa
Antisocial personality disorder
Anxiety (Unspecified)
Any diagnosis related to neglect or abuse
Any Psychotic disorder
Any Sexual Disorder
Any Sleep Disorder (Incl. Insomnia)
Any Substance Use Disorder
Autism spectrum disorder
Binge-eating disorder
Bipolar Disorder (Type I or II)
Body dysmorphic disorder
Borderline Personality Disorder
Bulimia Nervosa
Conduct disorder
Delusional disorder
Depression (Unspecified)
Dissociative identity disorder
Enuresis
Gambling disorder
Gender dysphoria
Generalized Anxiety
Hoarding disorder
Health anxiety
Intellectual disability
Intermittent explosive disorder
Kleptomania
Major Depressive Disorder
Narcissistic personality disorder
OCD
Oppositional defiant disorder
Overweight or obesity
Panic Disorder/Panic attacks
PDD (dysthymia)
Premenstrual dysphoric disorder
PTSD
Pyromania
Reactive attachment disorder
Separation anxiety disorder
Skin-Picking or Hair-Pulling
Social Anxiety
Specific learning disorder
Specific phobia
Tourette’s disorder
Unspecified personality disorder
12
Have you received a psychological diagnosis from a qualified healthcare professional?
ADHD (strategies to manage)
Adjustment disorder
Agoraphobia
Anorexia Nervosa
Antisocial personality disorder
Anxiety (Unspecified)
Any diagnosis related to neglect or abuse
Any Psychotic disorder
Any Sexual Disorder
Any Sleep Disorder (Incl. Insomnia)
Any Substance Use Disorder
Autism spectrum disorder
Binge-eating disorder
Bipolar Disorder (Type I or II)
Body dysmorphic disorder
Borderline Personality Disorder
Bulimia Nervosa
Conduct disorder
Delusional disorder
Depression (Unspecified)
Dissociative identity disorder
Enuresis
Gambling disorder
Gender dysphoria
Generalized Anxiety
Hoarding disorder
Health anxiety
Intellectual disability
Intermittent explosive disorder
Kleptomania
Major Depressive Disorder
Narcissistic personality disorder
OCD
Oppositional defiant disorder
Overweight or obesity
Panic Disorder/Panic attacks
PDD (dysthymia)
Premenstrual dysphoric disorder
PTSD
Pyromania
Reactive attachment disorder
Separation anxiety disorder
Skin-Picking or Hair-Pulling
Social Anxiety
Specific learning disorder
Specific phobia
Tourette’s disorder
Unspecified personality disorder
13
Are you currently taking any psychiatric medications?* This field is required.
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
14
SF - Are you currently taking any psychiatric medications?
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
15
Are you in touch with a physician about your mental health / medications?* This field is required.
No
Irregularly
A few times per year
Monthly or more
16
SF - Are you in touch with a physician about your mental health / medications?
No
Irregularly
A few times per year
Monthly or more
17
How often do you drink alcohol?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
18
SF - How often do you drink alcohol?
Daily
Weekly/Monthly
Infrequently/Never
19
How often do you engage in recreational drug use?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
20
SF - How often do you engage in recreational drug use?
Daily
Weekly/Monthly
Infrequently/Never
21
Have you received a diagnosis of a developmental disorder?Please list below. Skip if not applicable
22
Which DBT Group are you interested in?* This field is required.
Tuesdays starting August 13th 2024, 2-4PM EST / 12-2PM MST / 3-5PM AST
Wednesdays starting September 18th 2024, 6-8PM EST / 4-6PM MST / 7-9PM AST
Not sure - I would like to schedule a call to discuss
23
Have you previously completed a DBT program?* This field is required.
Yes
No
24
Do you feel comfortable being in a group of up to 10 participants?* This field is required.This is an online virtual group, but only your first name will be used in the group. Everyone will be asked to commit to confidentiality
Yes
No
Maybe. Want to talk to Layla/the therapist first
25
SF - Do you feel comfortable being in a group of up to 10 participants?This is an online virtual group, but only your first name will be used in the group. Everyone will be asked to commit to confidentiality
Yes
No
Maybe. Want to talk to Layla/the therapist first
26
Plan on using benefits?This group will be delivered by a Registered Therapist. Please check your insurance or let us know if we can help with that
Yes
No
Not Sure
27
SF - Plan on using benefits?
Yes
No
Not Sure
28
Program available to participants 18 years or older* This field is required. Layla's partner therapists for this program are licensed in Alberta, Nova Scotia, and Ontario. Therefore, this program is available only to residents of those provinces at this time.
29
Are you facing affordability barriers?* This field is required.
Yes: I would not be able to pay the program fee. I lack benefits and other means to pay
I am able to pay the fee
30
Would you like to be considered for Layla's Community Program for DBT Skills Groups?This initiative provides free spots in Layla’s Dialectical Behaviour Therapy (DBT) Skills Groups to individuals facing affordability barriers.
Yes
No
31
Healthcare Provider Referral / Recommendation: This program requires that you are referred or recommended to us by a registered healthcare provider, such as a family doctor, psychiatrist, nurse, or social worker* This field is required.Note: no physical referral needed, but name of provider required
I understand, and I will share the name of the recommending provider
32
Program limitation: Please note that this program requires a final eligibility assessment for DBT Skills by a Layla Program Facilitator* This field is required.
I understand
33
Name* This field is required.
First Name
Last Name
34
What pronouns do you use
She/her/hers
He/him/his
They/them/theirs
Other
35
What pronouns do you use* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
36
May we leave a voicemail?* This field is required.
Yes
No
37
SF - May we leave a voicemail?
Yes
No
38
Email* This field is required.
example@example.com
Confirm Email
39
Phone Number* This field is required.
Please enter a valid phone number.
40
Home Address* This field is required.Layla's partner therapists for this program are licensed in Alberta, British Columbia, Nova Scotia, and Ontario. Therefore, this program is available only to residents of those provinces at this time.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
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Dominica
Dominican Republic
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Egypt
El Salvador
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Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
41
Address - Text
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Large
Normal
Small
Ok
Ok
42
Date of Birth* This field is required.
Date
Year
Month
Day
43
Emergency contact - OLD* This field is required.Please provide name, phone, email, and relationship to you
Huge
Large
Normal
Small
Ok
Ok
44
Emergency Contact* This field is required.Please provide name, phone, email, and relationship to you The emergency contact will only be used if there is a concern for your safety. Your privacy is our priority, and we will handle this information with the utmost care.
45
How did you hear about us?* This field is required.A health and wellness professional is an expert who provides guidance and treatment to support physical, nutritional, or holistic well-being (i.e. chiropractor, physical therapist, dietician, massage therapist).
Family or friend
Online search
Family Doctor
Health/wellness professional
Other
46
Family Doctor Name* This field is required.If you're unable to provide your Family Doctor's name, please write NA in both the First Name and Last Name fields
First Name
Last Name
47
Family Doctor Clinic LocationPlease provide your Family Doctor's address or clinic name if that information is available or click NEXT to skip
48
For continuity of care, can we let your Family Doctor know the name of your therapist and appointment date if a match is made?* This field is required.
Yes
No
49
SF - For continuity of care, can we let your Family Doctor know the name of your therapist and appointment date if a match is made?
Yes
No
50
Family Doctor Phone Number* This field is required.
(###) ###-####
51
How did you hear about us?A health and wellness professional is an expert who provides guidance and treatment to support physical, nutritional, or holistic well-being (i.e. chiropractor, physical therapist, dietician, massage therapist).
Family or friend
Online search
Family Doctor
Health/wellness professional
Other
52
Family DoctorName and area/region
53
Referring Provider* This field is required.Name and area/region
54
Health/Wellness Professional Name* This field is required.
First Name
Last Name
55
Health/Wellness Professional Designation* This field is required.
Nurse Practitioner
Psychiatrist
Psychologist
Social Worker/Psychotherapist
Naturopath
Dietitian/Nutritionist
General Practitioner
Other healthcare provider
Other community worker
Pharmacist
56
SF - Health/Wellness Professional Designation
Nurse Practitioner
Psychiatrist
Psychologist
Social Worker/Psychotherapist
Naturopath
Dietitian/Nutritionist
General Practitioner
Other healthcare provider
Other community worker
57
Privacy of your information* This field is required.Layla respects your right to privacy. Please read our policy to understand how we collect and use personal information
58
Privacy of your information ( Click here to see Layla’s Privacy Policy)* This field is required.Layla respects your right to privacy. Please read our policy to understand how we collect and use personal information
I agree to Layla's Privacy Policy
59
Layla is not a crisis service* This field is required.If you or someone you know is in crisis or at risk of serious harm towards yourself or others, please call 911 or go to your nearest emergency room
60
Program Fee* This field is required.Layla's intake call is free. Fees for subsequent therapy sessions apply. This program is not covered by public health insurance. This program is offered at a total of $1100 including taxes, which covers all 12 sessions / 24 hours of the program. Individuals who complete the intake process and hold their spot in the program are eligible for early bird pricing of $900. This group will be delivered by a Registered Social Worker or Registered Psychotherapist. Please check your insurance or let us know if we can help with that.
61
Program Fee* This field is required.Layla's intake call is free. Fees for subsequent therapy sessions apply. This program is not covered by public health insurance. This program is offered at a total of $1100 including taxes if applicable, which covers all 12 sessions / 24 hours of the program. Individuals who complete the intake process and hold their spot in the program are eligible for early bird pricing of $900*. This group will be delivered by a Registered Social Worker or Registered Psychotherapist. Please check your insurance or let us know if we can help with that. * fee not applicable to free Layla Community DBT Skills Group if you are eligible
I understand
62
Therapist * This field is required.Your therapist is a registered clinician affiliated with Layla. Layla Care Inc. facilitates the connection between you and a therapist and strives to facilitate quality programming, however your therapist is independently governed by their regulatory bodies. Layla does not guarantee the therapist's ability to assist you. The therapists affiliated with Layla are solely responsible for delivering professional health services according to their clinical judgment. By using Layla's services, you agree to indemnify and hold Layla, its directors, officers, employees, agents, and shareholders harmless from any claims, demands, losses, liabilities, and expenses related to your use of Layla's services, healthcare services provided by an affiliated clinician facilitated by Layla, your violation of these terms, or your violation of the rights of any third party.
63
Your Therapist* This field is required.Your therapist is a registered clinician affiliated with Layla. Layla Care Inc. facilitates the connection between you and a therapist and strives to facilitate quality programming, however your therapist is independently governed by their regulatory bodies. Layla does not guarantee the therapist's ability to assist you. The therapists affiliated with Layla are solely responsible for delivering professional health services according to their clinical judgment. By using Layla's services, you agree to indemnify and hold Layla, its directors, officers, employees, agents, and shareholders harmless from any claims, demands, losses, liabilities, and expenses related to your use of Layla's services, healthcare services provided by an affiliated clinician facilitated by Layla, your violation of these terms, or your violation of the rights of any third party.
I understand and agree
64
Intake Form Complete - For Salesforce Integration
Intake Form Complete
65
Groups
DBT Skills Group
66
Global Modality
Individual
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