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 Δ 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: information@teampathways.com PHONE: (405) 607-4041 FAX: (405) 463-0090 FollowFollow SERVICES Individual CounselingFamily CounselingCouples CounselingChild/Teen CounselingCoachingSmall Groups