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CURRENT/NEW CLIENT FORMS

Complete the forms you need to begin or continue services with Quality Youth Services. These resources help our team gather important information, understand your needs, and support a smooth intake process.

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New Client Insurance Inquiry

Have questions about insurance coverage or whether QYS accepts your insurance plan? Complete this form to provide your information and allow our team to review your insurance options before beginning services.

Intake & Consent to Therapy Agreement

Complete this form to provide the information needed to begin mental health services with Quality Youth Services. It includes important intake information and consent for therapy.

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Release of Information

This form allows Quality Youth Services to communicate with designated individuals or organizations involved in your care. Complete the form to identify what information may be shared and with whom.

Payment Plan Application

Need assistance managing therapy-related payments? Complete this application to provide information for consideration of an available payment plan.

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Use of AI Tools Consent Form

This form provides information about the use of AI-supported tools in connection with services at Quality Youth Services and allows clients or authorized representatives to provide consent where applicable.

Referrals & Intake Forms

DHS Referral Form
For professionals and agencies referring clients to Quality Youth Services through DHS. Provide the requested referral information to help our team understand the client’s needs and begin the referral process.

DHS/JJS Intake Form

This intake form is for DHS/JJS clients. The client, case manager, parent, and QYS representative are required to complete the form to provide the information needed for intake and coordination of services.

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877-393-6232 
Fax: 877-393-6232
admin@qyservices.com

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Or contact us here

By calling or texting this number (877) 393-6232, customers agree to receive text messages. If you no longer wish to receive text messages, you may opt out at any time by replying "STOP".

QYS Clinical Services


2240 US-89 STE C
Harrisville, UT 84404

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1638 N 200 W STE H

Logan, UT 84341

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140 S Main St STE 1

Pleasant Grove, UT 84062

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©2021 BY QUALITY YOUTH SERVICES

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