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.
Email address *
Are you inquiring for yourself or someone else? *
First Name *
Your answer
Last Name *
Your answer
New Client's Date of Birth *
Your answer
Phone Number *
Your answer
What type of counseling services do you need? (Check all that apply.) *
Required
How can we help you? *
Your answer
How did you hear about us? *
Your answer
Do you have a provider preference?
Do you have any scheduling preferences (day and time)?
Your answer
How would you like us to follow up with you? *
If you will be using insurance, please fill out the information below.
Insurance Company
Your answer
Name of Insured
Your answer
Member ID Number
Your answer
Group ID Number
Your answer
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