Great Lakes Therapy Center

Name *

First Name

Last Name

Phone

(###)

###

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Preferred method of contact *

How would you like us to contact you?

Phone

Email

Preferred time of day to be contacted *

Monday to Friday: 8am-12pm

Monday to Friday: 12pm-4pm

Monday to Friday: 4pm-7pm

What service/services are you interested in?

DBT for Adults

DBT for Teens

Adult DBT Skills Groups

DBT for Substance Use Disorders and Addictive Behaviors

I'm not sure

How did you hear about us? *

Internet search

Facebook

Word of mouth

Other