Today's Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you referring yourself, or someone else for services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

This is Karen/Adilene {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DECLINED SERVICES {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name of Person Submitting This Request {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Referral Email Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Information:

Patient Legal Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

BirthDate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Client Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Preferred Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gender: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the Patient Have a Parent/Guardian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parent/Guardian Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parent/Guardian Phone Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parent/Guardian Address Same as Patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please note that documentation will be required to prove the legal right to sign the client up for services with Alliance Mental Health. This could be legal documentation or notarized documentation from a bio parent giving permission for you to sign paperwork to enroll the client in Mental Health services. You may upload documentation below or provide that to the therapist upon intake.

If you have any questions on what qualifies for such documentation please call 918-608-0380

Parent/Guardian Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parent/Guardian Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Phone: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Services Needed: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Notice to Mediation Managment Patients:

We do not prescribe Benzos or Medical Marijuana

How Urgent Is This Request? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Primary Reason for Referral: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

You selected an option that indicates that you or the person you are referring may need immediate medical or mental health attention. The inbox in which this referral goes is not montiored by a licensed mental health professional

If you or the person you are referring are currently in a mental health crisis, feeling suicidal, or having thoughts of harming themselves or others, please call 911 or go to your nearest emergency room.

Alliance Mental Health's crisis line can be reached at 918-608-0380 ext. 6

List of Oklahoma Inpatient Facilities:

The following facilities are authorized to preform emergancy evaluations for inpatient care 24/7:

Parkside - Tulsa- (918) 588-8888

Cedar Ridge- OKC- (405) 605-6111

Laurete- Tulsa- (918) 481-4000

Willow Crest- Miami- (918)-452-1836

Rolling Hills- Ada- (855) 408-9796

TMC Behavioral Health Hospital- Sherman Texas (accepts Oklahoma Medicaid)- (903) 416-3000

Insurance:

Select All That Apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Comments About Insurance: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Picture of Insurance Card: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Office Use Only:

Insurance Active? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Copay: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did You Know?

SoonerCare (Medicaid) offers 100% coverage for mental health services for those who qualify.

Income Guidelines for SoonerCare:

Household Size: Total Income:

1 $26,820

2 $36,216

3 $45,612

4 $55,044

5 $64,440

6 $73,836

7 $83,268

8 $93,264

SoonerCare also offers supplemental coverage for individual cases, which covers most copay costs.

If you need help applying, or have questions please contact our helpdesk at 918.608.0380

PLEASE NOTE:

Please select the methods we can contact you by: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Our team may reach out by text to confirm our attempts to contact you. No private information can be exchanged through texting, and a phone call will need to be scheduled.

Thank you for your understanding.

Please check your spam folder for further communications through email.

OFFICE USE ONLY:

SoonerCare has been checked through PICIS? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date Checked: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is This Therapist Doing Their Own Tx Plan/Assessment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assessment Team Only:

Client is ready to be assigned to therapist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Attempts:

Attempt {binding ItemNumber}

Contact Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Notes: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date Sent to Therapist: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}