ADHD Evaluation and Diagnosis

Company
This field is for validation purposes and should be left unchanged.
Client's Name*
Date of Birth for Identified Client*
Month
Day
Year
Phone*
Is it okay to text this number?*
- Yes
- No
Email*
Address*
Street Address City State ZIP Code
County*
i.e. Tulsa, Creek, Washington...
Is the identified client a child?*
- Yes
- No
- No but they do have a legal guardian
Is the child currently in DHS Custody?*
- Yes
- No
Name of DHS Case Worker*
Phone Number of DHS Case Worker*
County of current DHS case*
Parent or Guardian Name*
First and Last Name
Does the identified client have SoonerCare or Medicaid?*
- Yes, they ONLY have Medicaid
- No, they do not have Medicaid at all
- Yes but they ALSO have ANOTHER type of insurance
Select ALL insurance coverage that applies to this client - If you are completing this form on a computer hold ctrl or command to select more than one insurance*
Front and Back of All Health Insurance Cards Except Medicaid - Failure to include pictures of ALL insurance cards may delay services.*
Drop files here or

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 25 MB.
If cards are not provided and you incur charges that we are unable to submit to your insurance, you will be responsible for all charges not covered. If you are completing this form on your phone you can take a picture with your camera.
SoonerCare/Medicaid ID or Social Security Number*
If you do not know the SooneCare/Medicaid ID Number you must enter the client's social security number so we can look up the ID information.
Front of Photo ID for Primary Policy Holder*
Drop files here or

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 25 MB.
Allowed extensions: jpg,.png,.jpeg,.pdf

Find a Therapist that’s right for you

Our clinicians are trained in many areas of counseling, and we’ll tailor care around you—your needs, your goals, your pace.

Our Counselors Offer Therapy Sessions From Several Offices In Oklahoma

Telehealth is also available all across Oklahoma.

Tulsa (Main Location)

Tulsa (East Location)

Broken Arrow

Elk City

Coweta

Oklahoma City

Bartlesville

Owasso

Pryor

Sapulpa

Tahlequah

Sallisaw

Need Immediate Help?

If you are in crisis and need immediate help, please

CALL OR TEXT 988

For more information, go to: WWW.SUICIDOLOGY.ORG

MEDICAID
Aetna
Aetna Coventry
Alliance Coal
Allied National
BlueCross Blue Shield
ChampVA
Cigna EAP Services
Cigna Health and Life Insurance Co.
Edison Health Solutions
GPA
Group Benefit Services (GBS)
Health Smart
Healthcare Highways
HealthCare Solutions Group
HealthChoice
HealthScope
HealthSmart
HealthSmart Benefit Solutions
Humana Military
HumanaChoice PPO
Medica
Medicare
Meritain Health
OPTUM VA
The Kempton Group
Tricare East
UMR - Wausau/UHIS
United Health Care/United Behavioral Health
WebTPA