I am a clinician seeking information/wishing to make a referral N Y My Name(Required) First Last My Email Address(Required) Phone number(Required)Prospective Client(s) Age(s)(Required)Client's City/State(Required)Relationship to client (if other than self)?Referral SourceThis field is hidden when viewing the formPreferred Communication Email Text Phone Call Please select primary service of interest from below:Please select one primary service of interest from below:(Required)Select OneDBT Full (Individual Therapy + Skill Classes)DBT Skill Classes Only (*Requires Proof if an outside therapist)DBT for Children (8-10 years old)Trauma-focused Therapy (EMDR, DBT-PE)Psychological or Educational EvaluationsPlease select your DBT Skill Class preference Older teen and parent (13-17 years old/Middle and High School) Young adult (18-24 years old) Adult (25+ years old) Parent-only Select Older Teen and Parent Class(Required) Mondays, in-person in Orinda (6:15-7:45 pm) Wednesdays, in-person in Orinda (6:15-7:45 pm) Proof of an outside therapist is required to enroll in DBT Skill Classes, if you are not currently already seeing a Clearwater therapist. If selecting this option, please enter the name of your outside therapist here:(Required)Select Young Adult Class(Required) Wednesdays, in-person in Orinda (4-5:30 pm) Wednesdays, in-person in Orinda (4-5:30 pm) Select Adult Class(Required) Mondays, in-person in Orinda (10- 11:45 am) Tuesdays, ZOOM (6:15-8 pm) Select Parent-Only Class(Required) Thursdays, ZOOM (5:30-7:00 pm) Briefly share more information about why you/the client is seeking services from Clearwater at this timePhoneThis field is for validation purposes and should be left unchanged. 33478
