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