New Client Appointment Request
Thank you for contacting DBT Institute Oklahoma City! Our therapists maintain full schedules and by filling out the form below you will automatically be placed on our waitlist. We will follow up with you initially by e-mail at the first available opening.
Email address *
Are you inquiring for yourself or someone else? *
First Name *
Last Name *
New Client's Date of Birth *
Phone Number *
What type of services do you need? (Check all that apply.) *
Required
How can we help you? *
How did you hear about us? *
Describe any provider preferences you have.
Do you have any scheduling preferences (day and time)?
If you will be using insurance, please fill out the information below. We are in-network with Aetna, United Healthcare, HealthChoice, and a few others.
Insurance Company
Name of Insured
Member ID Number
Group ID Number
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of DBT Institute Oklahoma City. Report Abuse