Help Is Here

Whether you’re an individual seeking services for yourself or a loved one, or an organization referring someone for treatment, this is the place. Simply complete the form below, uploading any requested documentation, and click “submit.”

If you need assistance in requesting services, please call (844)458-2100.

Make a Referral Request Services

Make a Referral

Completing this digital referral will ensure the fastest response. If unable to complete your referral on our website, please fax referrals to (405) 551-8445 (for all GRAND locations).

BE ADVISED: This form is monitored 8 a.m. to 5 p.m., Monday through Friday. Responses are provided the next business day. If you are experiencing a crisis, please call our 24-hour Crisis Line at 1-800-722-3611.

*indicates required fields

Are you requesting services for yourself or a loved one?

Yes, for myself or a loved one.No, I’m making a referral from a partner organization.

Are the requested services for a child or adult? *

ChildAdult

Please confirm that this form is for a child. If the services request is not for a child, please select 'adult' from the dropdown above.*

Yes, this request is for a child.

Details of child requesting services

Date of request*

Legal name of child requesting services*

Birth date*

Gender *

Prefer to self describe:

Address*

Street

City

State

Zip Code

Which county is this request for?*

If Other, please type school name below.

Child's grade

What is the primary language of the child requesting services?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance

Parent/guardian name*

Relationship to child

Primary phone*

Secondary phone

Is the person submitting this form the child's guardian?*

YesNo

Is the parent/guardian aware that the request for services has been made?*

YesNo

Details of the person submitting this form

Name*

Relationship to child*

Phone*

Why are you requesting services? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 20 MB in size and is in one of the following formats: .pdf, .jpeg, or .png

Please confirm this service request is for an adult. If this request is not for an adult, please select 'child' from the dropdown above. *

Details of adult requesting services

Are you requesting services for yourself?

YesNo, I'm submitting this form for someone else.

Do you have a legal guardian?

YesNo

Name of legal guardian*

Guardian's relationship to you*

Phone*

Does this adult have a legal guardian?

NoYes, I am their legal guardianYes, but I am not their legal guardian

Details of person submitting form

Name*

Relationships to individual*

Phone*

Name of legal guardian*

Relationships to individual

Phone*

Details of person submitting form

Name*

Relationships to individual*

Phone*

Details of legal guardian

Name*

Relationships to individual

Phone*

Date of request*

Legal name of individual requesting services*

Birth date*

Gender *

Prefer to self describe:

Primary phone*

Secondary phone

Address*

Street

City

State

Zip Code

Please select the county in which you're seeking services*

What is the primary language of the individual requesting services?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance. If none, type "None" below.

Why are you requesting services? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 20 MB in size and is in one of the following formats: .pdf, .jpeg, or .png

Is this a DHS referral that is also related to a substance use assessment?*

YesNo

This form cannot be completed without the following requested documents. If you have questions about which files to submit or if you do not have these forms, email tanfcwreferrals@glmhc.net.

Referral for Substance Abuse Assessment Form 04MP033E*

Please upload a file that is no larger than 5 MB in size and is in one of the following formats: .pdf, .jpg, or .png

Consent for Release of Confidential Information Form 04MP001E*

Please upload a file that is no larger than 5 MB in size and is in one of the following formats: .pdf, .jpeg, or .png

Is this referral for a child or an adult?

ChildAdult

Please confirm that this referral is for a child. If this referral is not for a child, please select 'adult' from the dropdown above. *

Details of the child being referred

Date of referral*

Legal name of child being referred*

Birthdate*

Gender *

Prefer to self describe:

Address*

Street

City

State

Zip Code

Which county is this referral for?*

If Other, please type school name below.

Child's grade

What is the primary language of the child being referred?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance

Parent/guardian name*

Relationship to child

Primary phone*

Secondary phone

Is the person submitting this form the child's parent/guardian?

YesNo

Is the parent/guardian aware that the referral for services has been made?*

YesNo

Details of the person making the referral

Name*

Relationship to child being referred*

Phone*

What is the reason for this referral? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 10 MB in size and is in one of the following formats: .pdf, .jpg, or .png

Please confirm this service request is for an adult. If this request is not for an adult, please select 'child' from the dropdown above. *

Is the Individual aware of this referral? *

YesNo

Details of the individual being referred

Date of referral*

Legal name of individual being referred*

Birth date*

Gender *

Prefer to self describe:

Primary phone*

Secondary phone

Address*

Street

City

State

Zip Code

Please select the county in which you're seeking services*

What is the primary language of the individual being referred?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance. If none, type "None" below.

Does this adult have a legal guardian?

YesNo

Details of legal guardian

Name*

Relationships to individual

Phone*

Details of the person making the referral

Name*

Relationship to individual being referred*

Phone*

What is the reason for this referral? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 20 MB in size and is in one of the following formats: .pdf, .jpg, or .png

Is this referral for a child or an adult?

ChildAdult

Please confirm that this referral is for a child. If this referral is not for a child, please select 'adult' from the dropdown above. *

Details of the child being referred

Date of referral*

Legal name of child being referred*

Birth date*

Gender *

Prefer to self describe:

Address*

Street

City

State

Zip Code

Which county is this referral for?*

If Other, please type school name below.

Child's grade

What is the primary language of the child being referred?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance. If none, type "None" below.

Parent/guardian name*

Relationship to child

Primary phone*

Secondary phone

Is the person submitting this form the child's parent/guardian?*

YesNo

Is the parent/guardian aware that the referral for services has been made?*

YesNo

Details of the person submitting this form

Name*

Relationship to child being referred*

Phone*

Referring organization*

Please specify the law enforcement department.

If the individual has a chronic health condition, please specify.

Please specify the referring organization.

Please specify the school contact.

Please specify the referring organization.

What is the reason for this referral? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 20 MB in size and is in one of the following formats: .pdf, .jpg, or .png

Details of the person making the referral

Name*

Relationship to child being referred*

Phone*

Please confirm that this referral is for an adult. If this referral is not for an adult, please select 'child' from the dropdown above. *

Is this a NextGen referral?*

YesNo

Is this an Assisted Outpatient Treatment (AOT) referral-court-ordered outpatient treatment?*

YesNo

Is this individual aware of this referral?*

YesNo

Details of the individual being referred

Date of referral*

Legal name of individual being referred*

Birth date*

Gender *

Prefer to self describe:

Primary phone*

Secondary phone

Address*

Street

City

State

Zip Code

Please select the county in which you're seeking services*

If Other, please type school name below.

Child's grade

What is the primary language of the individual being referred?*

This individual uses Medicaid (SoonerCare)This individual uses MedicareThis individual uses other insurance

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance. If none, type "None" below.

Referring organization

Please specify the worker's name.

Please specify the worker's phone number.

Please specify the worker's name.

Please specify the worker's phone number.

Please specify the law enforcement department.

If the individual has a chronic health condition, please specify.

Please specify the referring organization.

Please specify the school contact.

Please specify the referring organization.

Does this adult have a legal guardian?

YesNo

Details of legal guardian

Name*

Relationships to individual

Phone*

Details of the person making the referral

Name*

Relationship to individual being referred*

Phone*

What is the reason for this referral? Please provide details.

Document Upload

Upload copies of any relevant documents (ID, SS card, insurance card, birth certificate). This is optional, but can help expedite the process.

Please upload a file that is no larger than 20 MB in size and is in one of the following formats: .pdf, .jpg, or .png

We’re sorry, your request can not be completed using our online referral form. Please follow these instructions:

For this contract (TANF or Child Welfare), we will need a copy of the Referral for Substance Abuse Assessment Form 04MP033E and a copy of the Consent for Release of Confidential Information Form 04MP001E. Both of these will need to be emailed to tanfcwreferrals@glmhc.net.