Dbt Diary Card
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1
2DBT Diary Card
NAME:
DATE:
Targets
Emotions
Self
Harm
Urge
Action
0-5
0-5
Urge
Action
Urge
Action
Urge
Action
Urge
Action
0-5
0-5
0-5
0-5
0-5
0-5
0-5
SUICIDAL IDEATION
: 0 = No thoughts 1 = Fleeting thoughts 2 = More intense 3 = Very Intense 4 = Developing specific plan 5 = Acting on plan
INTENSITY: 0 = Not at all 1 = A bit 2 = Somewhat 3 = Rather Strong 4 = VERY Strong 5 = EXTREMELY STRONG
How often did you fill in your diary card? _____ DAILY
______ 2 / 3 X’S WK
______ 1X WK
Urge to quit therapy? _______
Notes for the Week:
Mon
Agenda Items:
Tue
Wed
Thurs
Fri
Sat
Sun
Times needed to use telephone consultation? _______
Times did use telephone consultation? ______
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Parent category: Life