Adolescent DBT Diary Card                  
                                                                                    Date Began_________________ 
              Date       Self-Harm            Suicidal         Alcohol/Drugs         Meds         Other                              Emotions/Skills 
                       Urge     Action     Urge     Action    Urge     Action      Taken?                    Guilt   Anger  Fear      Happy      Anxious      Sad     Skills? 
                       0-5*     y/n        0-5*     y/n       0-5*     y/n         y/n                       0-5*    0-5*     0-5*    0-5*       0-5*         0-5*    0-7** 
                                                                                                                                                                       
               
                                                                                                                                                                       
               
                                                                                                                                                                       
               
                                                                                                                                                                       
               
                                                                                                                                                                       
               
                                                                                                                                                                       
               
                                                                                                                                                                       
               
               
              How often did you fill out this section?           Daily            2-3x             Once 
               
              *Rating scale for emotions and urges  
                            1                                2                               3                                4                               5 
                         Not at all                        A bit                         somewhat                       Rather strong                  Extremely strong 
               
              **Used Skills 
              0= not thought about or used                       4=Tried, could use them, but they didn’t help 
              1=Thought about, not used, didn’t want to          5=Tried, could use them, helped 
              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 
               
              What is my goal for the week?______________________________________________________________________________________ 
               
                                                               Adolescent Diary Card  Page 2 
                                                           Circle the days you worked on each skill 
            Core Mindfulness               Wise mind                                           Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Observe (just notice what is going on inside)       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Describe (Put words on the experience)              Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Participate(Enter into the experience)              Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Don’t Judge (nonjudgmental stance)                  Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Stay focused (one mindfully, in the moment)         Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Do what works (effectiveness)                       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
            Emotional Regulation           Identifying and labeling emotions                   Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           ABC                                                 Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           PLEASE (reduce vulnerability to emotion mind)       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Engaging in pleasant activities                     Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Working toward long-term goals                      Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Building structure//time, work, play                Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Acting opposite to current emotion                  Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
            Interpersonal Effectiveness    DEAR MAN (getting what you want)                    Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           GIVE (improving the relationship)                   Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           FAST (Feeling effective and keeping your self       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           respect) 
                                           Cheerleading statements for worry thoughts          Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
            Distress Tolerance             ACCEPTS (Distract)                                  Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Self-Soothe (Five senses)                           Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Pros and Cons                                       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Radical Acceptance                                  Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           TIP                                                 Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
            Other Skills                   Positive Reinforcement                              Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
            Middle Path                    Validate Self                                       Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Validate Someone else                               Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Think Dialectically (not black and white)           Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                           Act dialectically (walk the middle path)            Mon  Tues      Wed     Thurs    Fri    Sat    Sun 
                                                                                
            What good things happened this week?________________________________________________________________________________ 
            _______________________________________________________________________________________________________________