• New Client Referral Form   

    We are currently accepting new Telemed Clients throughout Oklahoma! 

    Our In-person options are limited at the moment:

    Southern Oklahoma, (Carter County Area)
    Both In-person and Telemed options are available

    Central Oklahoma (Oklahoma City, Yukon, Norman, Edmond Areas) Telemed only options available (no In-person at this time)

    (Areas outside of Southern and Central Oklahoma) 
    Telemed only options available (no In-person at this time)

    Please check back at a later time for more options - we apologize for any inconvenience. 

     

    ***If you have already confirmed services with a therapist and they have directed you to our website, please continue to the referral form below.*** 

  • Please select language / Por favor selecciona idioma*
  • Is this referral for Couples Counseling or Parenting?*
  • Insurance Type (if you have multiple insurance providers, please check all that apply)*
  • Tipo de Seguro (si tiene varios proveedores de seguros, marque todos los que correspondan)*
  • Format: (000) 000-0000.
  • Is Client 14 or older?*
  • El cliente es mayor de 14 anos?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is Making The Referral?*
  • Quien hace la referencia?*
  • Do you/client feel suicidal at this time?*
  • ¿Usted/cliente se siente suicida en este momento?*
  • Suicide Screening (C-SSR Self Report) Select any/all that apply:*
  • Have you been previously diagnosed?*
  • Services Requested:*
  • Servicios solicitados:*
  • Should be Empty: