YESS Counselling and Wellness LLC.

  • YESS Court Program Intake

    Complete this intake form using the same field texts and structure as closely as possible. Include the referenced participant, referral, program, consent, documentation, and office-use fields.

  • Participant Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Parent / Guardian and Emergency Contact (If participant is a minor)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Referral and Court Information

  • Date of Court Order / Referral
     - -
    2 digit month, 2 digit day, 4 digit year
  • Completion Due Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Program / Service Needs and Scheduling

    Check all that apply. Final enrollment is based on the referral/order, participant needs, and services available through YESS.
  • Programs / Services Needed
  • Additional Behavioral Health / Support Services Requested
  • Preferred Format
  • Previously completed a similar court-ordered class or program?
  • Currently receiving counseling, treatment, case management, probation, parole, or other support services?
  • Any current court dates, deadlines, or legal requirements YESS should know about?
  • Need documentation of enrollment, attendance, progress, or completion sent to a court or referring agency?

  • Documents and Reporting Information

  • Documents Received / Needed*
  • Format: (000) 000-0000.
  • Reporting / Completion Deadline
     - -
    2 digit month, 2 digit day, 4 digit year
  • Documentation Types Requested*

  • Consent and Acknowledgments

    I authorize YESS Wellness & Consulting Services, LLC to communicate with and release to the agency/person identified above information reasonably necessary to coordinate my court-related services, including enrollment status, attendance, participation/progress status, program completion, certificates of completion, and other documentation specifically required by the referral or court order. I understand that this authorization does not permit the release of unrelated confidential information and that additional authorization may be required for certain clinical, evaluation, testing, or otherwise protected records. I understand that I may ask questions about what information will be shared.
  • Consent Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Parent/Guardian Consent Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Acknowledgments & Participant Responsibilities*
  • Certification Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Parent/Guardian Certification Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Office Use Only

    NOT TO BE FILLED BY PARTICIPANT
  • Date Intake Received
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Expected Completion Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Certificate / Documentation Sent Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Yess Intake Fee*

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    YESS Intake Fee. Required one-time intake fee for YESS program enrollment.
    YESS Intake Fee

    Required one-time intake fee for YESS program enrollment.

    $40.00$40.00
      
    Total
    $0.00$0.00
    Payment Methods
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