Name *

First Name

Last Name

Phone *

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Interested In *

Standard DBT Services

PTSD/Trauma

Other

How did you hear about DBT Hamilton? *

Self Referral

Referred by another professional

Please check below if your referral pertains to the following:

Victim Services

Veterans Affairs Canada

Non-Insured Health Benefits for First Nations and Inuit (NIHB)

Email Consent *

*You will receive an email response from our team within 72 hours. (Please check your email junk folder if you don't see a response in your inbox). *I am providing consent for email communication. I wish to communicate with the DBT Hamilton Team via email. I acknowledge and understand that these email messages are not encrypted and that DBT Hamilton cannot guarantee the security of messages that I send or receive from my care provider. I agree not to use email to communicate emergency or urgent health matters. I acknowledge that at any time, I or my care provider can decide that we no longer wish to communicate through email. If I decide to stop communication through email, I agree to inform my care provider in writing or at my next appointment. By checking this box, I confirm that I have read and agree to these terms.

I Agree