DPC Waitlist Sign-up

Initial Screening Form
Full Name *

First Name Last Name
Child's Name

First Name Last Name
Child's Date of Birth *

Month Day Year
Relationship to Child:
Phone Number *
E-mail *
example@example.com
How did you hear about us?
Other
Please tell us about your concerns. *
Do you have any legal involvement (e.g., custody, child protective services, etc.)? If yes, please describe.
Do you have any safety concerns (e.g., harm to self, others, abuse)? If yes, please describe.
Would you like to use your insurance? (Please note: to use your insurance we will need to provide your insurance company with a mental health diagnosis.)

Yes, I will use insurance No, I will private pay Depends

Insurance Start
Insurance Carrier & Plan Info
Full Name of Primary Insured Subscriber

First Name Last Name
Date of Birth of Subscriber

Month Day Year
Subscriber ID
Please upload a photo of the front of your insurance card. (If you are not able to upload your card, or you don't have your card with you, please just provide your insurance provider and subscriber ID and DOB in the fields provided above.)

Cancel of
Please upload a photo of the back of your insurance card.

Cancel of
If you were planning to use your insurance, but we do not have a provider that accepts your insurance, are you willing to private pay?

Yes No Possibly

Insurance End
Scheduling availability: Our after school appointment times are EXTREMELY limited.

I need an after school appointment time, and I understand that may impact my ability to be served soon. I can make a daytime (9am-3pm) appointment work I am not sure about my schedule yet, please let me know the options.
If scheduling is a barrier, or you do not want your child to receive a mental health diagnosis, we also offer Parent Coaching. These are caregiver-only sessions to problem solve specific issues and provide individualized parenting tools to implement immediately. This is a short-term parent support program and is NOT a healthcare service therefore is not reimbursable by insurance. Are you interested in Parent Coaching? (See link/more info below).

Yes No Possibly
Parent Coaching packages are pre-paid on our website. Once you purchase a package, we will reach out to you to schedule. Appointments can generally be scheduled within one week. Click here to purchase or learn more.
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