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DBT PATH New Student Enrollment Form
Please take the time to carefully read each item on this form before submitting.
Student's First Name
*
Student's Last Name
*
PHYSICAL Street Address where student resides (billing address will be entered on the next page):
*
Physical Address Line 2
City
*
State/Province/Region
*
Zip/Postal Code
*
Phone Number
*
Country
*
Student's Email Address
*
Confirm Your Email Address
*
By providing my email address and signing up for this course, I consent to receive class-related emails, which may sometimes contain marketing content, and I understand that I can update my preferences anytime by using the link at the bottom of the emails I receive or through my student portal after logging in.
*
I confirm
Enrollment Code if provided one from DBT Path staff.
Is the student at least 18 years of age? (If not, you will be asked to enter the student's age.)
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Yes
No
How old is the student under age 18?
*
I confirm that I am a parent or guardian granting permission to a minor to attend this course and make this payment.
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Yes, I confirm.
Have you studied with us before and already have a username for our student portal?
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No
Yes
NOTE: After filling out this form, DO NOT CREATE A NEW USERNAME when you land on the page that asks you to create one. Your existing username will be reactivated when we process your enrollment.
What is your student portal username?
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Are you a therapist or other mental health or medical provider who may have clients currently attending our course?
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No
Yes
I am a therapist or other mental health or medical provider, and to the best of my knowledge, I do not have clients enrolled in the course at this time.
I understand, to avoid an ethical dilemma, as a therapist or other mental health or medical provider who may have clients in the course at the same time as me, I *cannot* use an alias and must attend under my true name. (If you are a therapist or mental or medical provider who is certain you do not have clients enrolled, you may use an alias to protect your privacy as you learn the skills and work through the course.)
*
Yes, I confirm.