How often did you fill out?

DBT Skills Card __ daily __ 2-3x. __ 4-6x. __ once

Date:
Circle Start Highest Urge to: Highest Rating Each Day: See Key Below Target 1 Target 2 Target 3
Day & Use * Kill Hurt Use Emotion Physical
Joy Used Skills:
to denote Myself Myself Subs. Misery Misery
acting on urge 0-5 0-5 0-5 0-5 0-5 0-5 0-7 0-5 0-5 0-5
MON
TUE
WED
THUR
FRI
SAT
SUN
Used skills
Homework assigned this week: 0=Not thought about or used 4=Tried, could do them but they
1=Thought about, not used, didn’t help
didn’t want to 5=Tried, could use them, helped
Homework results this week: 2=Thought about, not used, 6=Didn’t try, used them, didn’t
wanted to help
3=Tried but couldn’t use them 7=Didn’t try, used them, helped
Beliefs I can
Obstacles/ Coming into Coming into
Urge To: change/regulate
Judgments (0-5) Session (0-5) Session (0-5)
my:
Overall Progress This Week: Quit Therapy Emotions
Use Drugs Actions
1 2 3 4 5 Commit
A Lot Less No Change A Lot More Thoughts
Suicide
MON TUE WED THUR FRI SAT SUN SKILLS MODULE
Wise Mind: Acknowledge emotion & act skillfully
Observe: Just notice without words
Describe: Use factual words
MINDFUL-
Participate: Enter the experience
NESS SKILLS
Nonjudgmental Stance
One-Mindfully: One thing at a time
Effectiveness: Focus on what works
Dialectics
MIDDLE
Validation
PATH SKILLS
Behaviorism
STOP
Pros/Cons
TIPP
Distract with Wise Mind ACCEPTS
Self-Soothe with 5 Senses
DISTRESS
Improve the Moment
TOLERANCE
Radical Acceptance
Half Smile
Willing Hands
Alternate Rebellion
Urge Surfing
Check the Facts
Opposite to Emotion Action
Problem Solve EMOTION
PLEASE to Reduce Vulnerability REGULATION
Accumulate Positive Experience SKILLS

Build Mastery
Cope Ahead
Clarify Goals
DEAR MAN: to make or refuse request
GIVE: to maintain relationships INTERPER-
SONAL
FAST: to maintain self-respect SKILLS
SACRED: to build self-compassion
Committed Action Toward Values
 Substance School Suicidal
Sleep Eating Emotion Self-Harm Meds Target Target Target
Circle Abuse Work Thoughts
Problems Problems Misery Thoughts as Rx 1 2 3
Start Cravings Stress
Day Urge Used Action Urge Action Urge Action
0-5 0-5 0-5 0-5 Y/N 0-5 0-5 0-5
0-5 Y/N Y/N 0-5 Y/N 0-5 Y/N
MON
TUE
WED
THUR
FRI
SAT
SUN
Quit Exercise
Anxiety Anger Sad/Lonely Boredom Guilt/Shame Hope Contentment Pride
Therapy Duration
0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5
MON
TUE
WED
THUR
FRI
SAT
SUN
Overall Progress This Week: How often did you fill out? Date:
1 2 3 4 5
A Lot Less No Change A Lot More __ daily __ 2-3x. __ 4-6x. __ once
MON TUE WED THUR FRI SAT SUN SKILLS MODULE
Wise Mind: Acknowledge emotion & act skillfully
Observe: Just notice without words
Describe: Use factual words MINDFUL-
Participate: Enter the experience NESS
Nonjudgmental Stance SKILLS
One-Mindfully: One thing at a time
Effectiveness: Focus on what works
Dialectics MIDDLE
Validation PATH
Behaviorism SKILLS
STOP
Pros/Cons
TIPP
Distract with Wise Mind ACCEPTS
Self-Soothe with 5 Senses
DISTRESS
Improve the Moment
TOLERANCE
Radical Acceptance
Half Smile
Willing Hands
Alternate Rebellion
Urge Surfing
Check the Facts
Opposite to Emotion Action
Problem Solve EMOTION
PLEASE to Reduce Vulnerability REGULA-
Accumulate Positive Experience TION SKILLS

Build Mastery
Cope Ahead
Clarify Goals
DEAR MAN: to make or refuse request
GIVE: to maintain relationships INTERPER-
SONAL
FAST: to maintain self-respect SKILLS
SACRED: to build self-compassion
Committed Action Toward Values