Z REFERRALS CONTACT US REFERRAL FORM FOR SOMEONE ELSE "*" indicates required fields Referral source* First Last Phone*Email* Type of services you are seeking*DHS Court Ordered ServicesDHS Preventative ServicesTherapy ServicesCoaching ServicesMedical TreatmentOtherHow many people they selected to refer?*123456Person you are referring #1* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Person you are referring #2* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Person you are referring #3* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Person you are referring #4* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Person you are referring #5* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Person you are referring #6* First Last Gender* Male Female Race* Birth date* MM slash DD slash YYYY SSN* Medicaid number* Placement of person you are referring* First Last Address* Street Address City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Biological parent name* First Last Bio phone number*Parent phone number*What you are seeking*DHS Court Order ServicesDHS Prevention ServicesTherapy ServicesCoaching ServicesOtherChild/parent substance abuse* Yes No Co-occurring substance abuse/ mental health disorder* Yes No At risk of harming self/other?* Yes No What is your reason for seeking counseling?** First Last Phone **Email* I am Seeking*Individual TherapyCouples TherapyFamily TherapyWhat is your reason for seeking counseling?Insurance*AetnaBCBS (Blue Cross Blue Shield)WebTPAHealthchoiceMagellanMedicaid/SoonercareTricareUnitedSelf PayOtherPreferred time for callback*MorningLunchAfternoonEveningHow did you hear about Team Pathways?Name of your insurance company Let us help you find your path. Request an appointment LOCATE US 13707 Fairhill Avenue Edmond, Oklahoma 73013 GET DIRECTIONS JOIN OUR TEAM CONTACT US EMAIL: [email protected] PHONE: (405) 607-4041 FAX: (405) 463-0090 FollowFollow SERVICES Individual CounselingFamily CounselingCouples CounselingChild/Teen CounselingCoaching
