Youth Empowerment Program Registration

Enrollment History
Previous School 1
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 3
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Has this student participated in a
If the student has been detained in a juvenile detention center, please advise as to the offense. (This information will assist instructors in the application of skills discussed).
Leadership Contacts

To assist your youth in their academic and personal development, please provide the contact information for the counselor, coach, teacher, or spiritual leader you believe would support the efforts of your youth in this program.
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number

Program Day
Choose the preferred participation day and time
Parents, you can use your insurance for this skills development program. These group therapy sessions provide youth with skill building by a trained mental health professional to support the development of coping skills for social anxiety and depression. The following insurance plans are accepted:

Insurances:
- Aetna
- Ascension
- Blue Cross Blue Shield
- Bright Health Plan
- Centivo
- Cigna
- ClaimDOC
- Friday Health Plan
- Humana
- Medicare
- Moda
- Molina
- OccuNet
- Prime Health
- TriWest
- United Health Care
- Unity Preferred Network
- VNPN
Please complete this form by selecting payment for the workbook (insurance will not pay for supplies). Click the insurance link below to sign up with Sondermind for insurance billing. The link should open up another window;however, make sure to submit this form to ensure that your child is registered for the program. If you should have any questions or concerns, please feel free to contact me at dr.donettaquinones@gmail.com.
Please complete the information below if you will not be using insurance and will provide payment for your child's participation in the program.
My Products
prevnext( X )
Youth Empowerment Program$150.00
Participation Fee (6-week session) and workbook

Subtotal $0.00Tax $0.00Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Leadership Contacts