APPOINTMENT FORM - Family & Children's Services

Contact an Appointment Coordinator

If you would like to make an appointment, have questions or need more information, please call 918.587.9471 or you may also fill out the form below and one of our appointment coordinators will contact you.

Referral from Individual or Legal Guardian

Name (required)*
First Last
Phone Number (required)*
Email
Relationship to person for whom you are requesting services (if other than you)
Indicate preferred callback time between 8:30 a.m. – 4:00 p.m.

: Hours

Minutes

AM/PM

.
Message*
CAPTCHA
By providing a telephone number and submitting this form, you consent to receive calls and messages, including SMS text messages. We may use an automated dialer or prerecorded voice for voice messages. Message and data rates may apply. Message frequency may vary. You can opt out at any time by any reasonable method (such as replying STOP).

Referral from Organization or Provider

Name of person providing referral*
First Last
If this referral is from DHS and is for a child, is the child currently in DHS Custody?
- Yes
- No
- N/A
Phone number to call for more info if needed*
Client Name
First Last
Legal Guardian (if applicable)
First Last
Client Date of Birth
MM slash DD slash YYYY
Client Phone Number
Contact Email
Insurance Information(e.g., name of insurance, member ID, group ID) if available
Service Requested
CAPTCHA
By providing a telephone number and submitting this form, you consent to receive calls and messages, including SMS text messages. We may use an automated dialer or prerecorded voice for voice messages. Message and data rates may apply. Message frequency may vary. You can opt out at any time by any reasonable method (such as replying STOP).