If you have a Medicaid Eligible Child, Student, Adult or Patient who needs our services, please submit this form, or contact our office.

Our pledge to you is to make contact and start the Intake process within 24 hours of your referral. We want to do everything in our power to make this an easy, helpful process for everyone involved.

We are your eyes in your children’s home.
Phone: (405) 605-3093


Client's Information
       
Client's Name:   Gender:
DOB: Age: Race:
Medicaid #:   SSN:  
Caregiver(s) Name(s): Relationship to client:
   
   
Address:
Home Phone: Cell Phone: Other:
 

       
Caseworker/Other Information
Name:  
Phone 1:   Phone 2:   Fax #:
City: Email:
   
Presenting Problem:
 
 
  * Required fields