REFERRAL FOR INDIVIDUAL AND GROUP DBT SERVICES WITH ANDREW BERGLUNDYour Name(Required) First Last Preferred Name Date of Birth(Required) MM slash DD slash YYYY Age(Required) Gender Identity(Required)Mark all that apply Female Male Other Gender Currently Listed on Insurance Policy (Required to Bill Insurance)(Required) Female Male Other (As Stated Above) Other Gender Identity(Required) Pronouns(Required) She, her, hers He, him, his They, them, theirs Other Other Pronouns(Required) Contact InformationYour Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email Address(Required) Enter Email Confirm Email Primary Phone(Required)Secondary PhonePrimary Phone Type(Required) Cell Home Work Secondary Phone Type Cell Home Work Is it ok to leave you voicemails?(Required) Yes No Did either an agency, provider or individual refer you?(Required) Yes No Referral InformationFull Name(Required) Relationship to Client(Required) Agency Name PhoneAgency Address Street Address City State / Province / Region ZIP / Postal Code Have You Signed a Release?(Required) Yes No Do we have your permission to contact them?(Required) Yes No Reasons for Seeking TreatmentPlease Mark All That Apply(Required) Having Suicidal Thoughts Attempted Suicide In The Last 6 Months Self-Harming Behaviors Alcohol or Drug Abuse Eating Disorders Hospitalized in the past year for mental health reasons History of Assault/Violence towards others Homicidal Thoughts History of Trauma or Traumatic Experiences Other Reason for Seeking Treatment Other reason for seeking treatment(Required) Do you have access to a firearm?(Required) Yes No How Frequently to you have thoughts of Suicide?(Required) Suicide Attempts In Last 6 Months(Required) Yes No Date of most recent attempt(Required) What types of self-harming behaviors have your experienced?(Required) Burning Cutting Picking Other Other Self Harming Behaviors(Required) What substances or alcohol do you use?(Required) Eating Disorder Concerns(Required) Binging Purging Restricting Over-Exercise Other Other Eating Disorder Concerns(Required) Most recent date of hospitalization due to mental health reasons(Required) MM slash DD slash YYYY Hospitalization Information(Required)Is there currently any legal involvement?(Required)Mandatory Therapy, Restraining Order, etc.? Yes No Additional InformationInsuranceInsurance Company(Required) Member ID Number(Required) Group ID Number(Required) Provider or Customer Service Phone Number(Required)CAPTCHA