Adolescent Intensive Outpatient Eligibility Form
Difficulties in regulating painful emotions are central to the behavioral difficulties of many adolescents. From these individuals’ perspective, painful feelings are most often the “problems to be solved.” These behavioral difficulties might be considered ADHD, anxiety or depression as many of the symptoms and behaviors overlap and interact. For example, studies have found that having an anxiety disorder in early or middle childhood can increase your child’s risk of developing a depressive disorder in later adolescence. Both anxiety and depression can lead to dysfunctional behaviors, including suicidal behaviors, substance use, overeating, emotion suppression, overcontrol, and interpersonal mayhem, which are often behavioral solutions to intolerably painful emotions.

The Two Tents Intensive Outpatient Program (IOP) utilizes a blend of Dialect Behavioral Therapy - Skills (DBT-S), ACT (Acceptance Commitment Therapy) for Adolescents in the form of DNA-V and exposure therapy to help young people and their families find more effective ways to regulated their emotions and thereby, their behaviors. All three have decades of evidence in effectively treating anxiety, depression and the complication of ADHD. This is done in a group setting 3 hours a day, 4 days per week (Monday-Thursday), which is why it is considered intensive.

Complete this form if you are interested in our 3 hour, 4 day a week intensive group program for adolescents struggling with anxiety / depression. Once completed, our Clinical Intake Specialist, Katie Frits, will be in contact by email within two business days to schedule an in-person assessment. The assessment will be time for both parents and adolescent to share their struggles, concerns and goals while in the program. If you would prefer to be contacted via phone for scheduling, please note this in the form prior to submission.

If you are not interested in group and seeking an individual therapist call (913) 768-6606 or click here: https://forms.gle/oZ4czF2jKeZfjnVB6

If you have any trouble with this form call Renew at 913.768.6606 and press 0. 
Email address *
Insurance Company *
The Adolescent Intensive Outpatient Program (group therapy) is either in-network or we can usually get authorization (coverage) from these companies. We are not a covered service and cannot get coverage from KanCare (including Aetna KanCare), Medicaid or Medicare. For those families, we do offer a self-pay rate, scholarships and payment plan options. At the assessment we will provide you a written review of your insurance benefits and out-of-pocket costs, if possible.
Child's First Name *
Again, this eligibility form is for the Two Tents Intensive Outpatient Program (IOP) and will not get you connected to an individual therapist. See link above if seeking individual therapy. Thanks.
Child's Preferred Name (if different)
Child's Middle Initial
Child's Last Name *
Gender *
If "other" gender selected please explain
Date of Birth *
MM
/
DD
/
YYYY
Age
School Attending *
School Counselor
Grade Level *
School Accommodations? *
Next
Never submit passwords through Google Forms.
This form was created inside of Renew Counseling Center. Report Abuse