Class Online Payment

Online registration for summer 2018 DBT Boot Camp is currently open!

 

 

Patient Information
Participant's Name.
If participant is under 18, name of parent or guardian.
Optional. If the participant's phone is different than the payer's.
Please select the class you wish to attend.
If participant is a student, please enter the school or university where he/she is currently enrolled.
Please note participant's grade level if applicable.
Name of participant's current individual therapist within Peachtree DBT or within the community. Additional forms will be requested for those participants with a therapist within the community.
Payment Details
Person who will be submitting payment
**FOR 8 WEEK DBT SKILLS CLASSES: If the patient's therapist is not a part of Peachtree DBT, please choose the "Outside Therapist" option.**
I agree and consent to participation and the terms and conditions. I also understand my registration will not be complete until payment is received.
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