Radically Open DBT Tampa | SimplePractice

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Acknowledgement of Practice Limitations

Our practice is a small, boutique outpatient setting dedicated to providing thoughtful, personalized care to each client. Because of our size and structure, we are not equipped to safely treat individuals who are experiencing current safety concerns, including: - Active self‑harm or suicidal urges. - Active or ongoing emotional, psychological, physical or sexual abuse within the household. - Engaging in behavior that is dangerous to the safety or well-being of others. - Any situation requiring crisis intervention or a higher level of care. Clients with these needs require more intensive, immediate, or specialized services than we can provide. We will always help with appropriate referrals to ensure safety and support.

I acknowledge the limitations of this boutique outpatient practice and can attest that I do not have any current safety concerns (including active self‑harm, ). I acknowledge the limitations of this boutique outpatient practice and understand that I may have current safety concerns. I would like to schedule a paid consultation for recommendations and referral guidance rather than ongoing treatment.

Client Preferences

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For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.