📋 Outpatient Therapy/Youth & Family Services Inquiry Form

📋 Outpatient Therapy/Youth & Family Services Inquiry Form

Positive Alternatives & Outcomes
SECTION 1: Referral Source Info

If you are referring yourself of your child for Outpatient Therapy please skip to the next step.
Full Name
Agency or Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method

PhoneEmailText
Reason for Referral
Please include any behaviors, court involvement and school deficits here
SECTION 2: Client Info
Client Full Name
Date of Birth

MonthDayYear
Date
Age
Gender Identity

MaleFemaleOther
Race/Ethnicity

WhiteBlack or African AmericanAsianNative AmericanNative Hawaiian or Other Pacific IslanderMultiracial or Two or More RacesHispanic or LatinoOther
Current Living Situation
Parent/Guardian Name
Relationship to Client
Phone Number of Guardian
Please enter a valid phone number.Format: (000) 000-0000.
Email of Guardian
example@example.com
SECTION 3: School & Legal Info
Current School Attending
Grade Level
IEP or 504 Plan?

YesNo
Currently working with

DSSCSUSchool Admin (TRT, TSIS, DSIS, etc.)Other
Any legal concerns?

YesNo
Please provide more information
SECTION 4: Requested Services
What services are requested?

Outpatient TherapyFamily Empowerment SupportReunificationMentoringTutoringCustomized SupportCHINS Specific Family Support: BasicCHINS Specific Family Support: IntensiveStructured Suspension SupportSupervised Parent-Child Interaction SessionAnger Management ServicesIndependent Living & Career ReadinessOther
Preferred Language
Best Days/Times for Services
Safety Concerns or Accommodations?
How did you hear about us?
SECTION 5: Insurance Information (Outpatient Therapy ONLY)

Please provide your primary insurance details for outpatient therapy.
Insurance Provider
Enter the name of the insurance company.
Policy Holder Name

First NameLast Name
Policy or Member ID
Enter the insurance member or policy number.
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 6: Upload Files
Upload Relevant Documents

FAPT Approval, Court Order, IEP, Insurance Card for Therapy, etc.
Cancelof
Should be Empty:

📋 Outpatient Therapy/Youth & Family Services Inquiry Form

SECTION 1: Referral Source Info

SECTION 2: Client Info

SECTION 3: School & Legal Info

SECTION 4: Requested Services

SECTION 5: Insurance Information (Outpatient Therapy ONLY)

SECTION 6: Upload Files