Intake Form

Yes We Can Youth Clinics offers intensive treatment for teenagers and young adults (ages 13 to 25) struggling with mental health issues, behavioural problems and addictions. Parents or caregivers take part in a mandatory and impactful family programme.

You can start the registration process by filling in the form below. Once we receive your request, we will carefully review it and contact you within 24 hours to schedule a personal intake interview. We encourage you to check our current waiting times in advance.

During the intake, we’ll assess whether our programme is the right fit for the challenges you and your child are facing. Please make sure to bring the following documents to the intake — without them, the appointment cannot take place:

  • A valid ID card or passport (of the participant)

  • Relevant medical, psychological, or other reports

  • A complete medication list from your pharmacy

  • A medical ID card or health insurance policy

If you have any questions, our dedicated Case Management Team is here to help. You can reach them Monday to Friday from 8:30 a.m. to 10:00 p.m., and Saturday and Sunday from 10:00 a.m. to 4:00 p.m. (GMT+1) via +31 (0)85 02 01 222.
For more information about the costs of our programme, please visit our investment page.

Rest assured: all your questions, registration documents, and personal information will be treated with the highest level of confidentiality and care.

 
Information: Contact Person
Name
Address
Please include your country code (For example: +34 152112233)
By sending this form, I consent to the use of this data and its storage for a maximum of 3 years for the processing of my application at Yes We Can Youth Clinics.
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Information: Participant
Name


Address
For our records only, not to be contacted. Please include your country code (For example: +34 152112233)
For our records only, not to be contacted




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Family and Parental authority


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Problems of participant
General information family doctor
Please include your country code (For example: +34 152112233)






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Registration data
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