APPOINTMENT REQUEST FORM
YOUTH ENTERPRISE, INC.
CONTACT INFORMATION
Person Completing this Form:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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.
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
INSURANCE / FEES-FOR-SERVICE
I understand that Youth Enterprise, Inc. is a contract provider for the following insurance companies: Blue Shield, Cigna, and Optum/ United Behavioral Health.
*
Yes
I understand that if I am not covered by Blue Shield, Cigna, or Optum/ United Behavioral Health insurance, there will be out-of-pocket costs for services provided by Youth Enterprise, Inc. staff (e.g., I would pay for services upfront and seek reimbursement from my insurance company later).
*
Yes
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
What insurance does the individual being referred for services currently have (if none, type 'None'?
*
I would like to continue with scheduling an appointment for services:
*
Yes
No
SUBMIT
Should be Empty: