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The Family Therapy Clinic Appointment Request
Complete form to request a new appointment.
After submitting the form, you will be assigned to a provider and provider will contact you to schedule an appointment time and then will email directions for setting up client information online.
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Name
Your answer
Requesting Services for:
Self
Child/Adolescent
OCA Student
Couples
Family
Other:
Client's First & Last Name (if different)
Your answer
Client's Date of Birth
MM
/
DD
/
YYYY
Best Phone Number to Contact
Your answer
Email Address
Your answer
What concerns would you like to address in counseling?
Your answer
Any Preferences in provider (gender, age, religion, language, etc.)?
Your answer
Sliding Scale Fee Range
under $30,000 - $25
$30,000-50,000 - $35
$50,000-100,000 - $50
$100,000 up - $75
Clinic on the Hill
Lighthouse Clinic/HAU
Hilltop Clinic
Oakdale Public School
Oklahoma Christian Academy
Concerns about Fee; Provider will follow up
Available Appointment Times (click as many as possible)
Tuesday daytime (9am to 3pm)
Tuesday late afternoon/evening (4pm to 8pm)
Wednesday daytime (9am to 3pm)
Wednesday late afternoon/evening (4pm to 8pm)
Thursday daytime (9am to 3pm)
Thursday late afternoon/evening (4pm to 8pm)
Friday afternoon (1pm to 3pm)
Name of Another Adult coming to Appointment
Your answer
Email for Another Adult coming to Appointment
Your answer
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