Get Started with Services
Mental Health Client Initial Referral and Paperwork
Electronic Communication
Please check the box below to consent for Sunbeam to follow up with regarding this referral and scheduling via email.
I understand that by completing this form I am consenting for Sunbeam to communicate with me via the email listed below regarding my referral and possible future scheduling of services.
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I consent
Full Name of Client
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First Name
Last Name
Name of Person Completing Form
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First Name
Last Name
Relationship to Client
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Phone Number
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Please enter a valid phone number.
May we leave a message at the preferred number?
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Yes
No
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number of Client
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Date of Birth of Client
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Race (select all that apply) of Client
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American Indian/Alaskan
Asian
Black/African American
Hawaiian/Pacific Islander
Hispanic/Latino
White/Caucasian
Ethnicity of Client
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Hispanic/Latino
Not Hispanic/Latino
Sex (For Billing Purposes Only)of Client
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Please Select
Male
Female
Marital Status of Client
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Please Select
Single
Married
Widowed
Separated
Divorced
Domestic Partnership
Gender of Client
Pronouns of Client
He/Him
She/Her
They/Them
Other
Emergency Contact
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First Name
Last Name
Relationship to Client
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Phone Number of Emergency Contact
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Please enter a valid phone number.
Is Client under age 18?
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Yes
No
If under 18, Parent or Guardian Name
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First Name
Last Name
If under 18, is there a custody agreement in place?
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Yes
No
If under 18, is there currently DHS Custody?
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Yes
No
If Yes, DHS Worker Name
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First Name
Last Name
DHS Worker Email
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example@example.com
DHS Work Phone Number
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Please enter a valid phone number.
What type of mental health service are you looking for?
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Individual (Just me/Just client)
Couples
Family
Group: Making Sense of Your Worth
How can we help? (Select all that apply)
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Anxiety
Anger
Depression
Family Conflict
Grief/Loss
Trauma
Substance use
Victim of Crime
Work or School Issue
Other
Tell us what you're looking for in your counseling experience and specificallyin the therapist who works with you.
Tell us what you're looking
Tell us what you're looking for in your counseling experience and specifically in the therapist who works with you.
Mental Health
Within the last 90 days (3 months) have you had a significant period in which you have:
Experienced serious depression (felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficulty going about your daily activities?)
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Yes
No
Experienced hallucinations (heard or seen things others don't hear or see)?
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Yes
No
Experienced thoughts of harming yourself?
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Yes
No
Attempted suicide?
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Yes
No
Been prescribed medication for any psychological or emotional problem?
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Yes
No
Domestic Violence
Have you ever been afraid of your partner and/or a family member?
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Yes
No
Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone?
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Yes
No
If you answered yes to either of the above questions, is the person who hurt or threatened you still a part of your life?
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Yes
No
Have you ever used gestures, threats, and/or thrown or broken objects as a means to intimidate your partner or a family member?
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Yes
No
Have you ever pushed, restrained, hit, slapped, or used any other physical means to harm your partner or a family member?
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Yes
No
Trauma
Have you experienced a traumatic event and since had repeated nightmares/dreams and/or anxiety which interferes with you leading a normal life?
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Yes
No
Substance Use
During the past year, have you:
Drank alcohol and/or used drugs more than you intended?
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Yes
No
Tried to stop drinking alcohol and/or using other drugs, but couldn't?
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Yes
No
Experienced problems caused by drinking alcohol and/or using drugs, and you kept using?
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Yes
No
Drank alcohol and/or used other drugs to alter the way you feel?
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Yes
No
Been preoccupied with drinking alcohol and/or using other drugs?
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Yes
No
Needed to drink more alcohol and/or use more drugs to get the same effect you used to get with less?
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Yes
No
Pediatric Symptom Checklist (PSC)
Please indicate that which best describes your child:
Complains of aches and pains.
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Never
Sometimes
Often
Spends more time alone.
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Never
Sometimes
Often
Tires easily, has little energy.
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Never
Sometimes
Often
Fidgety, unable to sit still.
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Never
Sometimes
Often
Has trouble with teacher.
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Never
Sometimes
Often
Less interested in school.
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Never
Sometimes
Often
Acts as if driven by a motor.
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Never
Sometimes
Often
Daydreams too much.
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Never
Sometimes
Often
Distracted easily.
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Never
Sometimes
Often
Is afraid of new situations.
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Never
Sometimes
Often
Feels sad, unhappy.
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Never
Sometimes
Often
Is irritable, angry.
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Never
Sometimes
Often
Feels hopeless.
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Never
Sometimes
Often
Has trouble concentrating.
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Never
Sometimes
Often
Less interested in friends.
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Never
Sometimes
Often
Fights with other children.
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Never
Sometimes
Often
Absent from school.
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Never
Sometimes
Often
School grades dropping.
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Never
Sometimes
Often
Is down on themselves.
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Never
Sometimes
Often
Visits the doctor with doctor finding nothing wrong.
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Never
Sometimes
Often
Has trouble sleeping.
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Never
Sometimes
Often
Worries a lot.
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Never
Sometimes
Often
Wants to be with you more than before.
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Never
Sometimes
Often
Feels they are bad.
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Never
Sometimes
Often
Takes unnecessary risks.
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Never
Sometimes
Often
Gets hurt frequently.
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Never
Sometimes
Often
Seems to be having less fun.
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Never
Sometimes
Often
Acts younger than children their age.
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Never
Sometimes
Often
Does not listen to rules.
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Never
Sometimes
Often
Does not show feelings.
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Never
Sometimes
Often
Does not understand other people's feelings.
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Never
Sometimes
Often
Teases others.
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Never
Sometimes
Often
Blames others for their troubles.
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Never
Sometimes
Often
Takes things that do not belong to them.
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Never
Sometimes
Often
Refuses to share.
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Never
Sometimes
Often
Adverse Childhood Experience (ACE) Questionnaire
When growing up, during the first 18 years of life:
Did a parent or other adult in the household often swear at you, insult you, put you down, humiliate you or act in a way that made you afraid that you might be physically hurt?
Yes
No
Did a parent or other adult in the household often push, grab, slap, or throw something at you; or ever hit you so hard that you had marks or were injured?
Yes
No
Did an adult or person at least five years older than you ever touch or fondle you or have you touch their body in a sexual way; or try to actually have oral, anal, or vaginal sex with you?
Yes
No
Did you often feel that no one in your family loved you or thought you were important or special; or your family didn't look out for each other, feel close to each other, or support each other?
Yes
No
Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you; or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes
No
Were your parents ever separated or divorced?
Yes
No
Was your mother or step mother often pushed, grabbed, slapped, or had something thrown at her; or sometimes or often kicked, bitten, hit with a fist, or with something hard; or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes
No
Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes
No
Did a household member go to prison?
Yes
No
Please add up all of your "Yes" responses and put the total here:
Check all that apply
I (or my child) received services in the past at Sunbeam
I was referred by another agency
I have an open case with DHS
How did you hear about us?
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Boys and Girls Club
Bench Ad
Billboard
Bus Ad
Friend/Family Member
Internet
Newspaper
Palomar
Radio
Social Media
Sunbeam Early Childhood Services
Sunbeam Foster Care
Sunbeam Senior Engagement Program
TV
Work
Annual Income
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Number of Individuals Living in Household
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How will you be paying for services?
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Please Select
EAP
Commercial Insurance (BCBS, Aetna, etc.)
Self Pay/Sliding Scale
Medicaid
Other
Insurance Company
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Insurance Member ID Number
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Insurance Group Number
Name of Insured (if different from self)
First Name
Last Name
Date of Birth of Insured (if different from self)
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Month
-
Day
Year
Date
Social Security Number of Insured (if different from self)
If using an EAP or Mental Health Services benefit, what employer provides your benefit? If you do not see your employer below, please contact your HR to find out who your EAP services are through.
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Please Select
ARL Bio Pharma/DNA Solutions
Arts Council Oklahoma City
CASA of Oklahoma County
CityCare of OKC
Griffin Communications
Homeless Alliance
INASMUCH Foundation
Lilyfield
Lindsay Municipal Hospital
Lynn Health Institute
Modular Services Company
MTM Recognition
Neighborhood Services Organization
NewView Oklahoma
OCCHD
OKCNP
OK Housing Finance Agency
Palomar
Robinson Park
Sisu Youth Services
Stonecloud Brewing
WHYHR
Account Responsible Name (if self, leave blank; if parent/legal guardian, please fill out below)
First Name
Last Name
Account Responsible Date of Birth
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Month
-
Day
Year
Date
Account Responsible Phone
Please enter a valid phone number.
Account Responsible Email
example@example.com
Account Responsible Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Availability for Appointments (select all that apply)
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Monday
Tuesday
Wednesday
Thursday
Friday
Mornings (8am-Noon)
Afternoons (Noon-4pm)
Evenings (4pm-8pm)
By submitting this document:
I understand that completion of this document is for the purpose of determining client suitability for services and does not guarantee services provided by Sunbeam and that referral resources will be provided for those who do not qualify.
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