APPOINTMENT REQUEST FORM
YOUTH ENTERPRISE, INC.
CONTACT INFORMATION
Person Completing this Form:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am requesting an appointment for:
*
Myself
My child (minor under the age of 18)
If the individual requiring services is a minor, are you the minor's legal guardian?
*
Yes
No
N/A (I am an adult requesting services for myself, or the individual requiring services is a person of legal age, or I am at least 12 years of age and am seeking services for myself)
Name of child being referred for services
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Does the minor have the same residential address as the individual making this request for services?
Yes
No
Contact Number (individual referred for services)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (individual referred for services)
*
example@example.com
Address (individual referred for services)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REASON FOR REFERRAL (CHILD/ MINOR)
REFERRAL FOR CHILD/ MINOR (check all that apply):
*
Anxiety
Depression
Disruptive and Defiant Behaviors
Anger Outbursts
Temper Tantrums
Emotion Dysregulation
Physical Aggression (hitting, kicking, biting, throwing objects, etc.)
Verbal Aggression (threats, profanity, vulgar/ inappropriate language, etc.)
Mood Changes / Mood swings
Irritability
Separation Anxiety / Attachment Issues
Hyperactivity
Whinning / Crying / Screaming
Impulsivity
Clingy Behaviors
Inattention
Sleep Difficulties
Difficulty Following Directions
Difficult School Behaviors
Limited Social Skills
Truancy
Exposure to Trauma
Community Linkage of Services
Grief / Loss
Independent/ Daily Living Skills
Hygiene
Self-Advocacy Skills
Nutritional
Juvenile Justice/Court Involved
Medication Education
Delinquent Behaviors
Phobia/s
Self / Other Harm
Substance Use
Sustainable Employment
Whole Health/Wellness
Youth to Young Adult Transition
Lying
Stealing
Other
REASON FOR REFERRAL (ADULT/ CAREGIVER)
REFERRAL FOR CAREGIVER (check all that apply)
*
Maternal Mental Health Difficulties
Paternal Mental Health Difficulties
Perinatal/ Postpartum Anxiety
Perinatal/ Postpartum Depression
Perinatal/ Postpartum OCD
Perinatal/ Postpartum Psychosis
Mood Changes / Mood swings
Irritability
Difficulties with Attachment & Bonding
Sleep Difficulties
Lactation Challenges
Difficulties Managing Child's Behaviors
Parenting Classes
Parent Training & Education
Hyperactivity/ Impulsivity
Limited Social / Natural Supports
Other
TELEHEALTH SERVICES
Dr. Whitmore offers services via telehealth only at this time. If you require in-person services you may need to consider another provider. Would you like to proceed with requesting a telehealth appointment?
*
Yes
No
Type of service(s) being requested:
*
Individual Therapy
Parent-Child Interaction Therapy (PCIT)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Consultation Services Only for Parenting Support
Other
AVAILABILITY FOR SERVICES
Select the appointment day and time options that work best (select all that apply):
*
Thursday, before 3pm
Thursday, after 3pm
Friday, before 3pm
Friday, after 3pm
There is often longer waitlist times for afternoon or late afternoon appointments. Are you willing to accept morning appointments (if needed) in order to initiate services sooner? School notes can be provided to students.
*
Yes
No
INSURANCE / FEES-FOR-SERVICE
Name of Insurance Provider (e.g., Kaiser, Optum, Blue Cross, None, etc.)
*
If Youth Enterprise, Inc. is not contracted with your insurance provider, do you wish to proceed by paying for services out-of-pocket and seeking reimbursement from your insurance provider at a later date?
*
Yes
No
I understand that if my insurance does not cover the cost for services provided by Youth Enterprise, Inc., I can request the agency provide me with the necessary documentation to request reimbursement by my insurance company for out-of-pocket expenses paid.
*
Yes
I would like to continue with scheduling an appointment for services:
*
Yes
No
Submit
Should be Empty: