DBTeen Referral

DBTeen Referral Form

DBTeen is a dialectical behaviour therapy (DBT) program for young people aged 14-18 who exhibit difficulty regulating their emotions and behaviour. The Young Person completes the program with an adult living in the same residence.

For further information about the progam contact Lifeline WA DBTeen on 08 9261 4498 or visit our website.

If the Young Person is in crisis or in need of urgent assistance you can go to Head to Health to find services in your area. You could also contact Lifeline on 13 11 14, chat online or text 0477 13 11 14.

If you are experiencing difficulty submitting this form please email us at dbteen@lifelinewa.org.au

Now accepting referrals for Semester 1 2027.

Group sessions commence from the second week of February 2027

Bentley: Tuesday evenings
Landsdale: Tuesday evenings
Yangebup: Wednesday evenings
Rockingham: Saturday mornings
Shenton Park: Saturday mornings

*Please note, group locations and days are subject to change*

Step 1 of 7

About the Young Person

Please tell us about the Young Person who would like to be a part of Lifeline WA's 12-week DBTeen program.

Young Person's First Name(Required)

Young Person's Last Name(Required)

Is their chosen name different to their legal name?(Required)

Chosen First Name of Young Person

Chosen Last Name of Young Person

Young Person's Date of Birth(Required)

Young Person's Gender(Required)

Do they identify as LGBTQIA+?(Required)

Pronouns(Required)

Please specify pronouns for the Young Person

Street Address(Required)

Suburb(Required)

Postcode(Required)

Young Person's Email Address

Young Person's Phone Number

Is the Young Person of Aboriginal or Torres Strait Islander Australian descent?(Required)

Is the Young Person of a Culturally and Linguistically Diverse (CaLD) background?(Required)

Country of Birth(Required)

What is the main language spoken at home?(Required)

How well does the Young Person speak English?(Required)

DBTeen participation requires a reasonable level of written, read and spoken English.

Current School(Required)

Please notify us as soon as possible via email of any change in circumstances, including the school attended.

What year of school are they in?(Required)

Previous School/s

Has this young person completed DBTeen before?(Required)

Did they complete the full program?

Young person's presenting issues

Does the Young Person have a GP Mental Health Treatment Plan?(Required)

Principal Diagnosis(Required)

Additional Diagnosis

If applicable

Does the Young Person have any disability?(Required)

Does the Young Person take any medications?(Required)

Please list the medications(Required)

Has the Young Person made a suicide attempt in the past?(Required)

Is there anything else you can tell us about the Young Person?

DBTeen Referral Form

About the Young Person

About the Adult

About the Referrer

About the Referrer

Young person's presenting issues

GP details

Other mental health professionals

Professional 1

Professional 2

Professional 3

Permission & Consent