New Client Services Request

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Notice: Completing this form indicates an interest in starting services. This form is not your intake paperwork. A clinician will contact you to schedule a meeting to complete your intake paperwork.

• Client's Name*
• Date of Birth for Identified Client*
  Month

  Day

  Year
• Phone*
• Is it okay to text this number?*
  • Yes
  • No
• Email*
• 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
• Reason for Seeking Services*
  You may be as broad or specific as you choose
• Check all locations you would consider going to*
  • Tulsa - 61st and Lewis
  • Tulsa - 41st and Hwy 169
  • Tulsa West/Sand Springs
  • Broken Arrow
  • Coweta
  • Elk City
  • Oklahoma City
  • Owasso
  • Pryor
  • Sapulpa
  • Sallisaw
  • Skiatook
  • Stillwater
  • Tahlequah
  • Home
  • Virtual
• City/Town of Residence*
• Would you like virtual appointments*
  • Yes
  • No
  • No Preference
  • Unsure - Would like more information
• Would it be okay to have a counseling intern shadow your therapist during sessions?*
  • Yes
  • No
  • Yes but I would like more information about the intern before they join
  • I would like more information
  You always have the option to change your mind about allowing interns to join. You also have the right to ask for specific requirements of the interns if you do allow them to join (i.e. you only want a male or female intern, LGBTQ friendly, etc.)
• Would you be interested in seeing a Counselor in Training Graduate Student in order to be seen more quickly?*
  • Yes
  • No
  • No Preference
  • Unsure - Would like more information
• Do you have a preferred clinician you want to see?*
  • Yes
  • No
  * Listing a preference does not guarantee you will be able to see that clinician. It will be dependent on their availability. If your preferred clinician is not available we will try to find someone that may have a similar counseling style.
• Preferred Clinicians Name*
• Do you have a preference on a male or a female counselor?
  • No Preference
  • Male
  • Female
• 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*
  MEDICAIDAetnaAetna CoventryAlliance CoalAllied NationalBlueCross Blue ShieldChampVACigna EAP ServicesCigna Health and Life Insurance Co.Edison Health SolutionsEMPAC EAPGPAGroup Benefit Services (GBS)Health SmartHealthcare HighwaysHealthCare Solutions GroupHealthChoiceHealthScopeHealthSmartHealthSmart Benefit SolutionsHumana MilitaryHumanaChoice PPOMedicaMedicareMeritain HealthOPTUM VAThe Kempton GroupTricare EastUMR - Wausau/UHISUnited Health Care/United Behavioral HealthWebTPA
• 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 Select files

  Accepted file types: jpg, png, jpeg, pdf, Max. file size: 10 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.
• Is anyone else in your household seeking or receiving services from Improving Lives Counseling Services*
  • Yes
  • No
• Please list names of all other household members seeking/receiving services so we can coordinate services*
  Click on the + button to add additional lines
• Phone
  This field is for validation purposes and should be left unchanged.

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