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

Patient Information:

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{ binding firstError.message }
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If same as legal name, leave blank

Gender: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Patient Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Does the Patient Have a Parent/Guardian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Parent/Guardian Address Same as Patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Parent/Guardian Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Services Needed: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How Urgent Is This Request? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Primary Reason for Referral: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

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

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Insurance:

Select All That Apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

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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

 

 

 

 

 

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PLEASE NOTE:

If you are submitting this request on behalf of someone, please let them know how we will contact them.

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

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.

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OFFICE USE ONLY:

SoonerCare has been checked through PICIS? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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Is This Therapist Doing Their Own Tx Plan/Assessment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Assessment Team Only:

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

EX: no show, consents signed, rescheduled

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Today's Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you referring yourself, or someone else for services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
This is Karen/Adilene {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name of Person Submitting This Request {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Referral Email Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Patient Information:

Patient Legal Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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BirthDate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Client Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Preferred Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Does the Patient Have a Parent/Guardian? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Relation to Client: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent/Guardian Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent/Guardian Phone Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent/Guardian Address Same as Patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent/Guardian Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent/Guardian Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Phone: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Preferred Office: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Preferred Therapist {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Services Needed: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How Urgent Is This Request? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Primary Reason for Referral: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

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

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Insurance:

Select All That Apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Comments About Insurance: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Policy # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Picture of Insurance Card: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
{ binding firstError.message }

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

 

 

 

 

 

{ binding firstError.message }

PLEASE NOTE:

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

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.

{ binding firstError.message }

OFFICE USE ONLY:

SoonerCare has been checked through PICIS? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Billing System: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Is This Therapist Doing Their Own Tx Plan/Assessment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Therapist: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Assessment Team Member {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Therapist: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Assessment Team Only:

Client is ready to be assigned to therapist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Contact Attempts:
Attempt {binding ItemNumber}
Contact Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Notes: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Date Sent to Therapist: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }