Initials ID# Filled out in session? How often did you fill out this side?

Date Started
DBT Diary Card Yes No Daily 2-3 Times Once

Skills Used (0-7)

Urges to… Actions Emotions Behaviors

Joy (0-5)
Self-Harm

Self-Harm
Day
Suicide

Suicide
(Y/N)

(Y/N)

(Y/N)

(Y/N)
(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)
# Specify # Specify # Specify # Specify

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

USED SKILLS:
0=Not thought about or used
1=Thought about, not used, didn’t want to
2=Thought about, not used, wanted to
3=Tried but couldn’t use them
4=Tried, could use them but they didn’t help
5=Tried, could use them, helped
6=Didn’t try, used them, didn’t help
7=Didn’t try, used them, helped

Events to note during the week: Thurs

Mon Fri

Tue Sat

Wed Sun
 Instructions: Filled out in session? How often did you fill out this side?
Skills Diary Card Circle the days you worked on each skill Yes No Daily 2-3 Times Once

1. Wise Mind Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. Observe: Just Notice Monday Tuesday Wednesday Thursday Friday Saturday Sunday
3. Describe: Put Words On Monday Tuesday Wednesday Thursday Friday Saturday Sunday
4. Participate: Enter into the Experience Monday Tuesday Wednesday Thursday Friday Saturday Sunday
5. Non-Judgmental Stance Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6. One-Mindfully: In-the-Moment Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7. Effectiveness: Focus on What Works Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8. Objective Effectiveness: DEAR MAN Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9. Relationship Effectiveness: GIVE Monday Tuesday Wednesday Thursday Friday Saturday Sunday
10. Self-Respect Effectiveness: FAST Monday Tuesday Wednesday Thursday Friday Saturday Sunday
11. Reduce Vulnerability: PLEASE Monday Tuesday Wednesday Thursday Friday Saturday Sunday
12. Build MASTERY Monday Tuesday Wednesday Thursday Friday Saturday Sunday
13. Build Positive Experiences Monday Tuesday Wednesday Thursday Friday Saturday Sunday
14. Opposite-to-Emotion Action Monday Tuesday Wednesday Thursday Friday Saturday Sunday
15. TIP Skills / STOP Skills Monday Tuesday Wednesday Thursday Friday Saturday Sunday
16. Distract Monday Tuesday Wednesday Thursday Friday Saturday Sunday
17. Self-Soothe Monday Tuesday Wednesday Thursday Friday Saturday Sunday
18. Improve the Moment Monday Tuesday Wednesday Thursday Friday Saturday Sunday
19. Pros and Cons Monday Tuesday Wednesday Thursday Friday Saturday Sunday
20. Radical Acceptance Monday Tuesday Wednesday Thursday Friday Saturday Sunday
21. Building Structure//Work Monday Tuesday Wednesday Thursday Friday Saturday Sunday
22. Building Structure//Love Monday Tuesday Wednesday Thursday Friday Saturday Sunday
23. Building Structure//Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
24. Building Structure//Place Monday Tuesday Wednesday Thursday Friday Saturday Sunday
 Initials ID# 是否在治疗室填写? 在过去一周的时间，您多久填写一次呢？ 开始日期
DBT Diary Card Yes No 每日填写 2-3 次 1次

有冲动想要… 行动 情绪 行为

使用技巧
喜悦 (0-5)

(0-7)
自伤行为

自伤行为
Day

(Y/N)

(Y/N)

(Y/N)

(Y/N)
自杀

自杀
(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)

(0-5)
# 注记 # 注记 # 注记 # 注记

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

使用技巧使用:
0=没有想到或使用技巧 4=想过使用技巧，但没有使用
1=想过使用技巧，但没有使用，不想使用 5=想过使用技巧，但没有使用，有效果
2=想过使用技巧，但没有使用，想使用 6=没有想过使用技巧，使用技巧，没效果
3=想过使用技巧，但不能使用 7=没有想过使用技巧，使用技巧，有效果

过去一周发生事件记录： Thurs

Mon Fri

Tue Sat

Wed Sun
 指导语： 是否在治疗室填写? 在过去一周的时间，您多久填写一次呢?
Skills Diary Card 请将您有练习技巧的日子画圈 Yes No 每日填写 2-3 次 1次

1. 智慧心 Wise Mind Monday Tuesday Wednesday Thursday Friday Saturday Sunday
2. 观察 Observe: Just Notice Monday Tuesday Wednesday Thursday Friday Saturday Sunday
3. 描述 Describe: Put Words On Monday Tuesday Wednesday Thursday Friday Saturday Sunday
4. 参与 Participate: Enter into the Experience Monday Tuesday Wednesday Thursday Friday Saturday Sunday
5. 不评断 Non-Judgmental Stance Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6. 专一地做 One-Mindfully: In-the-Moment Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7. 有效地做 Effectiveness: Focus on What Works Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8. 目标效能 Objective Effectiveness: DEAR MAN Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9. 人际效能 Relationship Effectiveness: GIVE Monday Tuesday Wednesday Thursday Friday Saturday Sunday
10. 自我尊重效能 Self-Respect Effectiveness: FAST Monday Tuesday Wednesday Thursday Friday Saturday Sunday
11. 减少脆弱心 Reduce Vulnerability: PLEASE Monday Tuesday Wednesday Thursday Friday Saturday Sunday
12. 建立自我掌控 Build MASTERY Monday Tuesday Wednesday Thursday Friday Saturday Sunday
13. 建立 Build Positive Experiences Monday Tuesday Wednesday Thursday Friday Saturday Sunday
14. 相反行动 Opposite-to-Emotion Action Monday Tuesday Wednesday Thursday Friday Saturday Sunday
15. TIP/STOP（立即停止）技巧 TIP Skills / STOP Skills Monday Tuesday Wednesday Thursday Friday Saturday Sunday
16. 转移注意力 Distract Monday Tuesday Wednesday Thursday Friday Saturday Sunday
17. 自我抚慰 Self-Soothe Monday Tuesday Wednesday Thursday Friday Saturday Sunday
18. 改善当下 Improve the Moment Monday Tuesday Wednesday Thursday Friday Saturday Sunday
19. 优缺点分析 Pros and Cons Monday Tuesday Wednesday Thursday Friday Saturday Sunday
20. 全然接纳 Radical Acceptance Monday Tuesday Wednesday Thursday Friday Saturday Sunday
21. Building Structure//Work Monday Tuesday Wednesday Thursday Friday Saturday Sunday
22. Building Structure//Love Monday Tuesday Wednesday Thursday Friday Saturday Sunday
23. Building Structure//Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
24. Building Structure//Place Monday Tuesday Wednesday Thursday Friday Saturday Sunday