DBT                          First Name                                         Filled out in session? Y/N                       How often did you fill out this section?                                           Date started 
          Adolescent Diary Card                                                                                                                            
                                                                                                                                                                     ____daily   ____2-3x   ___Once 
       Date          Self Harm                  Suicidal                  Alcohol                 Drugs                   Meds                               Other                                                 Emotions                                                      
                   Urge      Actions       Thoughts       Actions      Urge       Use        Urge        Use       Taken as       Risky         Cut                          Anger     Fear       Happy       Anxious      Sad       Shame        Misery       Skills        Notes 
                                                                                 amount                Amount         pre-         Sex        Class/ 
                                                                                  type                   type       scribed                   School 
                   0-5        Y/N            0-5            Y/N        0-5                    0-5                    Y/N          Y/N          Y/N                            0-5       0-5        0-5          0-5        0-5        0-5          0-5          0-7              
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
                                                                                                                                                                                                                                                              
        
       USED SKILLS                                                                                                                           Rating Scale for Emotions and Urges: 
       0 = Not thought about or used                                    4 = Tried, could do them but they didn’t help                         
       1 = Thought about, not used, didn’t want to               5 = Tried, could use them, helped                                                0 = Not at all   1 = A Bit   2 = Somewhat   3 = Rather Strong   4 = Very Strong   5 = Extremely Strong 
       2 = Thought about, not used, wanted to                     6 = Didn’t try, used them, didn’t help                                                                                                          
       3 = Tried, but couldn’t use them                                 7 = Didn’t try, used them, helped                                                                        Urge to quit therapy: _____     Misery Index: _____ 
       Instructions: Circle the days you worked on each skill 
                   1. Wise mind                                    Mon      Tue       Wed          Thu       Fri      Sat       Sun                       15. DEAR MAN (Getting what you want)                  Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          s                                                                                                                                     l   s
          s                                                                                                                                     a   s
          e        2. Observe (just notice what’s going on         Mon  Tue           Wed          Thu       Fri      Sat       Sun             n   e     16. GIVE (Improving the relationship)                 Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          n                                                                                                                                     o   n
          l        inside)                                                                                                                      s   e
                                                                                                                                                r   v
          u                                                                                                                                     e   i
          f        3. Describe (Put words on the                   Mon  Tue           Wed          Thu       Fri      Sat       Sun             p   t     17. FAST (Feeling effective and keeping your          Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          d                                                                                                                                     r   c
          n        experience)                                                                                                                  e   e     self-respect) 
          i                                                                                                                                     t   f
                                                                                                                                                n   f
          m        4. Participate (Enter into the experience       Mon  Tue           Wed          Thu       Fri      Sat       Sun             I   E     18. Cheerleading statements for worry                 Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                                                                                                                                                          thoughts 
          e
          r                                                                                                                                           
          o        5. Don’t Judge (Non-judgmental stance)          Mon  Tue           Wed          Thu       Fri      Sat       Sun              s   e    19. ACCEPTS (Distract)                                Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          C                                                                                                                                      s   c
                   6. Stay focused (One-mindfully: in the          Mon  Tue           Wed          Thu       Fri      Sat       Sun              e   n    20. Self-soothe (5 senses)                            Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                   moment)                                                                                                                       r   a
                                                                                                                                                 t   r
                                                                                                                                                 s   e
                                                                                                                                                 i   l
                   7. Do What Works (Effectiveness)                Mon  Tue           Wed          Thu       Fri      Sat       Sun              D   o    21 Pros and cons                                      Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                   8. Identifying and labeling emotions            Mon  Tue           Wed          Thu       Fri      Sat       Sun                  T    22. Radical acceptance                                Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          n
          o        9. PLEASE (Reduce vulnerability to              Mon  Tue           Wed          Thu       Fri      Sat       Sun                       23. IMPROVE (improve the moment)                      Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          i
          t        emotion mind) 
          a
          l
          u        10. ABC (Building mastery, feeling              Mon  Tue           Wed          Thu       Fri      Sat       Sun                       24. Half Smile                                        Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          g        effective) 
          e                                                                                                                                              
          R        11. Engaging in pleasant activities             Mon  Tue           Wed          Thu       Fri      Sat       Sun                  e    25. Positive reinforcement                            Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                                                                                                                                                 g   l  h
          n        12. Working toward long-term goals              Mon  Tue           Wed          Thu       Fri      Sat       Sun              n   d  t 26. Validate self                                     Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          o                                                                                                                                      i      a
          i        13. Building structure – time, work, play                                                                                     k   d  P 27. Validate someone else 
          t                                                        Mon  Tue           Wed          Thu       Fri      Sat       Sun              l   i                                                          Mon       Tue       Wed         Thu       Fri       Sat      Sun 
          o                                                                                                                                      a   M
          m        14. Opposite action                             Mon  Tue           Wed          Thu       Fri      Sat       Sun              W        28. Think dialectically (not black & white)           Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                                                                                                                                                     e
          E                                                        Mon  Tue           Wed          Thu       Fri      Sat       Sun                  h    29. Act dialectically (walk the middle path)          Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                                                                                                                                                     t
                    
                                                                   Mon  Tue           Wed          Thu       Fri      Sat       Sun                                                                             Mon       Tue       Wed         Thu       Fri       Sat      Sun 
                                                                                                                                               
                   Breathing Exercise                              Mon  Tue           Wed          Thu       Fri      Sat       Sun                                                                             Mon       Tue       Wed         Thu       Fri       Sat      Sun