New Client Appointment Request
Thank you for contacting DBT Institute Oklahoma City! Please fill out the form below and we will follow up with you as soon as possible to schedule a first appointment or provide a referral based on your needs and preferences.
Are you inquiring for yourself or someone else?
Date of Birth
What type of counseling services do you need? (Check all that apply.)
How can we help you?
How did you hear about us?
Do you have a provider preference?
Jill Marshall LPC Candidate
Amanda Shrader LCSW
Shayla Hanna LPC/LADC Candidate
Sarah Zimmer Intern
Kris Bryant LPC
Do you have any scheduling preferences (day and time)?
If you will be using insurance, please fill out the information below.
Name of Insured
Member ID Number
Group ID Number
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of DBT Institute Oklahoma City.
Terms of Service