Help Is Here

Date of request*

Legal name of child requesting services*

Birth date*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Street

City

State

Zip Code

Which county is this request for?*

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

Please select a school district in Craig County.

—Please choose an option—Bluejacket Public SchoolsCowboy Junction Christian SchoolKetchum Public SchoolsVinita Public SchoolWelch Public SchoolWhite Oak Public School

Please select which school this child attends.

—Please choose an option—Bluejacket Elementary SchoolBluejacket High SchoolBluejacket Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Cowboy Junction SchoolOther

Please select which school this child attends.

—Please choose an option—Ketchum Elementary SchoolKetchum High SchoolKetchum Middle SchoolKetchum Seventh Day Adventist AcademyOther

Please select which school this child attends.

—Please choose an option—Hall-Halsell Elementary SchoolVinita High SchoolVinita Middle SchoolWill Rogers Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Welch Elementary SchoolWelch High SchoolWelch Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—White Oak Elementary SchoolWhite Oak High SchoolOther

If Other, please type school name below.

Please select a school district in Delaware County.

—Please choose an option—Christian Hills Christian SchoolColcord Public SchoolsGrove Public SchoolsJay Public SchoolsKansas Public SchoolsKenwood Public SchoolsLeach Public SchoolsMoseley Public SchoolOaks - Mission Public SchoolWestville Public School

Please select which school this child attends.

—Please choose an option—Cookson Hills Christian SchoolOther

Please select which school this child attends.

—Please choose an option—Colcord Alternative EducationColcord Elementary SchoolColcord Head StartColcord High SchoolColcord Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Grove Alternative SchoolGrove Early Childhood CenterGrove Head StartGrove High SchoolGrove Lower Elementary SchoolGrove Middle SchoolGrove Upper Elementary SchoolGrove Virtual SchoolOther

Please select which school this child attends.

—Please choose an option—Jay Alternative EducationJay Cherokee Nation Head StartJay Elementary SchoolJay Head StartJay High SchoolJay Lower Elementary SchoolJay Middle SchoolJay Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Kansas Alternative SchoolKansas Elementary SchoolKansas Head StartKansas High SchoolKansas Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Kenwood Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Leach Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Moseley Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Oaks-Mission Elementary SchoolOaks-Mission Middle SchoolOaks-Missoin High SchoolOther

Please select which school this child attends.

—Please choose an option—Westville High SchoolWestville Skelly Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Kay County.

—Please choose an option—Blackwell Public SchoolsNewkirk Public SchoolPonca City Public SchoolTonkawa Public School

Please select which school this child attends.

—Please choose an option—Blackwell Elementary SchoolBlackwell Head StartBlackwell High SchoolBlackwell Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Newkirk Braman ElementaryNewkirk High SchoolNewkirk Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Garfield Elementary SchoolLiberty Elementary SchoolLincoln Elementary SchoolPonca City Alternative Wildcate AcademyPonca City East Middle SchoolPonca City Head StartPonca City High SchoolPonca City Virtual AcademyPonca City West Middle SchoolRoosevelt Elementary SchoolTrout Elementary SchoolUnion Elementary SchoolWashington Pre K Center SchoolWoodlands Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Tonkawa Elementary SchoolTonkawa HIgh SchoolTonkawa Middle SchoolOther

If Other, please type school name below.

Please select a school district in Mayes County.

—Please choose an option—Adair Public SchoolsChouteau - Mazie Public SchoolsLocust Grove Public SchoolsOsage Public SchoolPryor Public SchoolSalina Public SchoolWickliffe Public School

Please select which school this child attends.

—Please choose an option—Adair High SchoolAdair Middle SchoolBernita Hughes Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Chouteau Early Learning CenterChouteau Elementary SchoolChouteau-Mazie High SchoolChouteau-Mazie Middle SchoolMazie Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Locust Grove Early Learning CenterLocust Grove High SchoolLocust Grove Middle SchoolLocust Grove Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Osage Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jefferson Elementary SchoolLincoln Elementary SchoolPryor High SchoolPryor Junior High SchoolPryor Middle SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Salina Elementary SchoolSalina High SchoolSalina Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wickliffe Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Noble County.

—Please choose an option—Berryhill Public SchoolsFrontier Public SchoolsMorrison Public SchoolPerry Public School

Please select which school this child attends.

—Please choose an option—Billings ElementaryBillings High SchoolOther

Please select which school this child attends.

—Please choose an option—Frontier Elementary SchoolFrontier High SchoolOther

Please select which school this child attends.

—Please choose an option—Morrison Elementary SchoolMorrison High SchoolMorrison Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Perry High SchoolPerry Junior High SchoolPerry Lower Elementary SchoolPerry Upper Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Nowata County.

—Please choose an option—Nowata Public SchoolOklahoma Union Public SchoolSouth Coffeyville Public School

Please select which school this child attends.

—Please choose an option—Nowata Alternative District I-40Nowata Elementary SchoolNowata High SchoolNowata Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oklahoma Union ElementaryOklahoma Union High SchoolOklahoma Union Middle SchoolOther

Please select which school this child attends.

—Please choose an option—South Coffeyville Elementary SchoolSouth Coffeyville High SchoolSouth Coffeyville Middle SchoolOther

If Other, please type school name below.

Please select a school district in Osage County.

—Please choose an option—Barnsdall Public SchoolsHominy Public SchoolsPawhuska Public SchoolPrue Public SchoolSkiatook Public SchoolsShidler Public SchoolWoodland Public SchoolWynona Public School

Please select which school this child attends.

—Please choose an option—Barnsdall Elementary SchoolBarnsdall High SchoolBarnsdall Junior HighOther

Please select which school this child attends.

—Please choose an option—Hominy Early Childhood CenterHominy High SchoolHominy Middle SchoolHorace Mann Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Indian Camp Elementary SchoolPawhuska Elementary SchoolPawhuska High SchoolPawhuska Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Prue Elementary SchoolPrue High SchoolOther

Please select which school this child attends.

—Please choose an option—Shidler High SchoolShidler Middle SchoolWard Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Woodland Elementary SchoolWoodland High SchoolWoodland Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Wynona Elementary SchoolWynona High SchoolOther

Please select which school this child attends.

—Please choose an option—Marrs Elementary SchoolNewman Middle SchoolSkiatook ElementarySkiatook High SchoolSkiatook Middle SchoolSkiatook Intermediate Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Ottawa County.

—Please choose an option—Adair Public SchoolsCleora Public SchoolsCommerce Public SchoolsFairland Public SchoolsMiami Public SchoolQuapaw Public SchoolTurkey Ford Public SchoolWyandotte Public School

Please select which school this child attends.

—Please choose an option—Afton Elementary SchoolAfton High SchoolOther

Please select which school this child attends.

—Please choose an option—Cleora ElementaryOther

Please select which school this child attends.

—Please choose an option—Alexander Elementary SchoolCommerce High SchoolCommerce Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Fairland Elementary SchoolFairland High SchoolFairland Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Miami AcademyMiami High SchoolMiami Jr High SchoolNichols Elementary SchoolWashington Elementary SchoolWilson Elementary SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Quapaw Elementary SchoolQuapaw Elementary SchoolQuapaw Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wyandotte Elementary SchoolWyandotte Junior Senior High SchoolOther

Please select which school this child attends.

—Please choose an option—Turkey Ford Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Pawnee County.

—Please choose an option—Cleveland Public SchoolsJennings Public SchoolsMannford Public SchoolsPawnee Public Schools

Please select which school this child attends.

—Please choose an option—Cleveland High SchoolCleveland Intermediate Elementary SchoolCleveland Middle SchoolCleveland Primary Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jennings Public SchoolOther

Please select which school this child attends.

—Please choose an option—Mannford Elementary SchoolMannford High SchoolMannford Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Pawnee Elementary SchoolPawnee High SchoolPawnee Middle SchoolOther

If Other, please type school name below.

Please select a school district in Payne County.

—Please choose an option—Cushing Public SchoolsGlencoe Public SchoolsOak Grove Public SchoolPerkins-Tryon Public SchoolRipley Public SchoolStillwater Public SchoolYale Public Schools

Please select which school this child attends.

—Please choose an option—Cushing High SchoolCushing Lower Elementary SchoolCushing Middle SchoolCushing Upper Elementary SchoolCushing Wilson SchoolOther

Please select which school this child attends.

—Please choose an option—Glencoe Elementary SchoolGlencoe High SchoolOther

Please select which school this child attends.

—Please choose an option—Oak Grove Public SchoolOther

Please select which school this child attends.

—Please choose an option—Perkins-Tryon Elementary SchoolPerkins-Tryon High SchoolPerkins-Tryon Intermediate SchoolPerkins-Tryon Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Ripley Elementary SchoolRipley High SchoolOther

Please select which school this child attends.

—Please choose an option—Highland Park Elementary SchoolLincoln AcademyRichmond Elementary SchoolSangre Ridge Elementary SchoolSkyline Elementary SchoolStillwater High SchoolStillwater Jr. High SchoolStillwater Middle SchoolWestwood Elementary SchoolWill Rogers Elementary SchoolStillwater Pioneer Virtual AcademyOther

Please select which school this child attends.

—Please choose an option—Yale Elementary SchoolYale High SchoolYale Middle SchoolOther

If Other, please type school name below.

Please select a school district in Rogers County.

—Please choose an option—Catoosa Public SchoolsClaremore Public SchoolsCollinsville Public SchoolsFoyil Public SchoolsInola Public SchoolsOologah Public SchoolOwasso Public SchoolSequoyah Public SchoolsVerdigris Public Schools

Please select which school this child attends.

—Please choose an option—Art Goad ElementaryCatoosa High SchoolChelsea High SchoolChelsea Middle SchoolCherokee Elementary SchoolHelen Paul Learning CenterWells Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Catalayah Elementary SchoolClaremont Elementary SchoolClaremore High SchoolJustus-Tiawah North CampusJustus-Tiawah South CampusRoosa Elementary SchoolWestside Elementary SchoolWill Rogers Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—Foyil Elementary SchoolFoyil High SchoolFoyil Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Inola Elementary SchoolInola High SchoolInola Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oologah-Talala High SchoolOologah-Talala Lower Elementary SchoolOologah-Talala Middle SchoolOologah-Talala Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Pamela Hodson ElementaryStone Canyon ElementaryOther

Please select which school this child attends.

—Please choose an option—Sequoyah Elementary SchoolSequoyah High SchoolSequoyah Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Verdigris Elementary SchoolVerdigris High SchoolVerdigris Junior High SchoolVerdigris Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Collinsville High SchoolCollinsville Middle SchoolCollinsville Upper Elementary SchoolHerald Lower ElementaryJanice K. Pollard ECCWilson 6th Grade CenterOther

If Other, please type school name below.

Please select a school district in Tulsa County.

—Please choose an option—Berryhill Public SchoolsBixby Public SchoolsBroken Arrow Public SchoolsGlenpool Public SchoolsJenks Public SchoolsOwasso Public SchoolPrivateSand Springs Public SchoolSperry Public SchoolsSummit Christian AcademyTulsa Public SchoolUnion Public Schools

Please select which school this child attends.

—Please choose an option—Berryhill ElementaryBerryhill High SchoolBerryhill Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Bixby 9th Grade CenterBixby Alternative EducationBixby Central ElementaryBixby Central Intermediate SchoolBixby East ElementaryBixby East Intermediate SchoolBixby High SchoolBixby Middle SchoolBixby North ElementaryBixby North Intermediate SchoolBixby West ElementaryBixby West Intermediate SchoolOther

Please select which school this child attends.

—Please choose an option—Arrow Springs Early ChildhoodArrowhead ElementaryAspen Creek Early ChildhoodAspen Creek ElementaryBA Options Academy AlternativeBroken Arrow High SchoolCentennial Middle SchoolChilders Middle SchoolCountry Lane IntermediateCountry Lane PrimaryCreekwood Early ChildhoodCreekwood ElementaryFreshman AcademyHighland Park ElementaryLeisure Park ElementaryLiberty ElementaryLynn Wood ElementaryOak Crest ElementaryOliver Middle SchoolOneta Ridge Middle SchoolPark Lane Early ChildhoodRhoades ElementaryRosewood ElementarySequoyah Middle SchoolSpring Creek ElementaryTimber Ridge ElementaryVandever ElementaryVanguard AcademyVirtual AcademyWolf Creek ElementaryOther

Please select which school this child attends.

—Please choose an option—Glenpool ElementaryGlenpool High SchoolGlenpool IntermediateGlenpool Lower ElementaryGlenpool Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Jenks Alternative CenterJenks East ElementaryJenks East IntermediateJenks Freshman AcademyJenks High SchoolJenks Middle SchoolJenks Northwest ElementaryJenks Southeast ElementaryJenks West ElementaryJenks West IntermediateOther

Please select which school this child attends.

—Please choose an option—Smith Elementary SchoolAtor Elementary SchoolBailey Elementary SchoolBarnes Elementary SchoolHudson ElementaryMills Elementary SchoolMorrow Elementary SchoolOwasso 6th Grade CenterOwasso 7th Grade CenterOwasso 8th Grade CenterOwasso High SchoolOwasso Northeast Elementary SchoolRam Academy - AlternativeOther

Please select which school this child attends.

—Please choose an option—Bishop Kelly High SchoolOther

Please select which school this child attends.

—Please choose an option—Sand Springs 6th Grade CenterSand Springs Angus Vallen ElementarySand Springs Charles Page High SchoolSand Springs Clyde Boyd Middle SchoolSand Springs CPHS Freshman AcademySand Springs Early Childhood Education CenterSand Springs Garfield STEAM AcademySand Springs Limestone Technology AcademySand Springs Northwest Fine Arts AcademySand Springs Page Academy Alternative High SchoolSand Springs Pratt ElementaryOther

Please select which school this child attends.

—Please choose an option—Sperry Elementary SchoolSperry High SchoolSperry Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Summit Christian AcademyOther

Please select which school this child attends.

—Please choose an option—Memorial High SchoolThoreau Demonstration Academy Middle SchoolTulsa - East Central High SchoolWhitman ElementaryBell ElementaryBooker T. Washington High SchoolBurroughs ElementaryCAP Tulsa (Pre-K & Early Childhood)Carnegie ElementaryCarver Middle SchoolCelia Clinton ElementaryCentral High SchoolCentral Middle SchoolClinton West ElementaryCollege Bound Academy ElementaryCollegiate Hall Elementary & MiddleCooper ElementaryCornerstone (Pre-K & Early Childhood)Council Oak ElementaryCrosstown (Pre-K & Early Childhood)Daniel Webster High SchoolDaniel Webster Middle SchoolDisney ElementaryDolores Huerta ElementaryEast Central Junior High SchoolEdison Prepatory High SchoolEdison Prepatory Middle SchoolEducare (Pre-K & Early Childhood)Eisenhower International Elementary MagnetEliot ElementaryEmerson ElementaryEugene Field ElementaryFelicitas Mendez International ElementaryGreenwood Leadership Academy ElementaryGrissom ElementaryHale High SchoolHamilton ElementaryHawthorne ElementaryHenry Zarrow International Elementary MagnetHoover ElementaryJohn Hope Franklin ElementaryKendall-Whittier ElementaryKerr Elementary SchoolKey ElementaryKIPP Tulsa University Prep High SchoolLanier ElementaryLewis and Clark ElementaryLindbergh ElementaryMacArthur ElementaryMarshall ElementaryMayo Demonstration Elementary (Magnet)McClure ElementaryMcKinely ElementaryMcLain High SchoolMitchell ElementaryMonroe Demonstration Academy Middle SchoolNorth Star Academy High - AlternativeOwen ElementaryPatrick Henry ElementaryPeary ElementaryPhoenix Rising High School - AlternativeRobertson ElementarySalk ElementarySequoyah ElementarySkelly ElementarySpringdale ElementaryStreet School High School - AlternativeTulsa Anderson ElementaryTulsa Honor Academy High SchoolTulsa Honor Academy Middle SchoolTulsa Legacy Charter Primary Academy (Elem)Tulsa Legacy Charter Upper Academy (Middle)Tulsa MET High School - AlternativeTulsa MET Middle - AlternativeTulsa School of Arts and Sciences High SchoolTulsa Tech Career AcademyTulsa Virtual Academy ElementaryTulsa Virtual Academy HighTulsa Virtual Academy MiddleUnity Learning Academy ElementaryWayman Tisdale Fine Arts Academy ElementaryWill Rogers College High SchoolWill Rogers College Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Union 8th Grade Center6th & 7th Grade CenterBoevers ElementaryBroken Arrow Anderson ElementaryCedar Ridge ElementaryDarnaby ElementaryEllen Ochoa ElementaryGrove ElementaryJarman ElementaryJefferson ElementaryMcAuliffe ElementaryMoore ElementaryPeters ElementaryRosa Parks Early ChildhoodRosa Parks ElementaryRoy Clark ElementaryUHS Freshman AcademyUnion Alternative SchoolUnion High SchoolOther

If Other, please type school name below.

Please select a school district in Washington County.

—Please choose an option—Bartlesville Public SchoolsCaney Valley Public SchoolsCopan Public SchoolsDewey Public Schools

Please select which school this child attends.

—Please choose an option—Bartlesville High SchoolMadison Middle SchoolRanch Heights Elementary SchoolRichard Kane Elementary SchoolWayside Elementary SchoolWoodrow Wilson ElementaryJane Phillips Elementary SchoolHoover Elementary SchoolCentral Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Caney Valley Elementary School - OchelataCaney Valley High SchoolOther

Please select which school this child attends.

—Please choose an option—Copan High SchoolOther

Please select which school this child attends.

—Please choose an option—Dewey Elementary SchoolDewey High SchoolDewey Middle SchoolOther

If Other, please type school name below.

Child's grade

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

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance

Parent/guardian name*

Relationship to child

Primary phone*

Secondary phone

Email

Name*

Relationship to child*

Phone*

Email

Why are you requesting services? Please provide details.

Name of legal guardian*

Guardian's relationship to you*

Phone*

Email

Name*

Relationships to individual*

Phone*

Email

Name of legal guardian*

Relationships to individual

Phone*

Email

Name*

Relationships to individual*

Phone*

Email

Name*

Relationships to individual

Phone*

Email

Date of request*

Legal name of individual requesting services*

Birth date*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Primary phone*

Secondary phone

Street

City

State

Zip Code

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

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

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

Medicaid (SoonerCare) Member Number

Medicare Member Number

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

Why are you requesting services? Please provide details.

Date of referral*

Legal name of child being referred*

Birthdate*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Street

City

State

Zip Code

Which county is this referral for?*

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

Please select a school district in Craig County.

—Please choose an option—Bluejacket Public SchoolsCowboy Junction Christian SchoolKetchum Public SchoolsVinita Public SchoolWelch Public SchoolWhite Oak Public School

Please select which school this child attends.

—Please choose an option—Bluejacket Elementary SchoolBluejacket High SchoolBluejacket Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Cowboy Junction SchoolOther

Please select which school this child attends.

—Please choose an option—Ketchum Elementary SchoolKetchum High SchoolKetchum Middle SchoolKetchum Seventh Day Adventist AcademyOther

Please select which school this child attends.

—Please choose an option—Hall-Halsell Elementary SchoolVinita High SchoolVinita Middle SchoolWill Rogers Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Welch Elementary SchoolWelch High SchoolWelch Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—White Oak Elementary SchoolWhite Oak High SchoolOther

If Other, please type school name below.

Please select a school district in Delaware County.

—Please choose an option—Christian Hills Christian SchoolColcord Public SchoolsGrove Public SchoolsJay Public SchoolsKansas Public SchoolsKenwood Public SchoolsLeach Public SchoolsMoseley Public SchoolOaks - Mission Public SchoolWestville Public School

Please select which school this child attends.

—Please choose an option—Cookson Hills Christian SchoolOther

Please select which school this child attends.

—Please choose an option—Colcord Alternative EducationColcord Elementary SchoolColcord Head StartColcord High SchoolColcord Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Grove Alternative SchoolGrove Early Childhood CenterGrove Head StartGrove High SchoolGrove Lower Elementary SchoolGrove Middle SchoolGrove Upper Elementary SchoolGrove Virtual SchoolOther

Please select which school this child attends.

—Please choose an option—Jay Alternative EducationJay Cherokee Nation Head StartJay Elementary SchoolJay Head StartJay High SchoolJay Lower Elementary SchoolJay Middle SchoolJay Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Kansas Alternative SchoolKansas Elementary SchoolKansas Head StartKansas High SchoolKansas Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Kenwood Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Leach Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Moseley Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Oaks-Mission Elementary SchoolOaks-Mission Middle SchoolOaks-Missoin High SchoolOther

Please select which school this child attends.

—Please choose an option—Westville High SchoolWestville Skelly Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Kay County.

—Please choose an option—Blackwell Public SchoolsNewkirk Public SchoolPonca City Public SchoolTonkawa Public School

Please select which school this child attends.

—Please choose an option—Blackwell Elementary SchoolBlackwell Head StartBlackwell High SchoolBlackwell Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Newkirk Braman ElementaryNewkirk High SchoolNewkirk Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Garfield Elementary SchoolLiberty Elementary SchoolLincoln Elementary SchoolPonca City Alternative Wildcate AcademyPonca City East Middle SchoolPonca City Head StartPonca City High SchoolPonca City Virtual AcademyPonca City West Middle SchoolRoosevelt Elementary SchoolTrout Elementary SchoolUnion Elementary SchoolWashington Pre K Center SchoolWoodlands Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Tonkawa Elementary SchoolTonkawa HIgh SchoolTonkawa Middle SchoolOther

If Other, please type school name below.

Please select a school district in Mayes County.

—Please choose an option—Adair Public SchoolsChouteau - Mazie Public SchoolsLocust Grove Public SchoolsOsage Public SchoolPryor Public SchoolSalina Public SchoolWickliffe Public School

Please select which school this child attends.

—Please choose an option—Adair High SchoolAdair Middle SchoolBernita Hughes Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Chouteau Early Learning CenterChouteau Elementary SchoolChouteau-Mazie High SchoolChouteau-Mazie Middle SchoolMazie Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Locust Grove Early Learning CenterLocust Grove High SchoolLocust Grove Middle SchoolLocust Grove Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Osage Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jefferson Elementary SchoolLincoln Elementary SchoolPryor High SchoolPryor Junior High SchoolPryor Middle SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Salina Elementary SchoolSalina High SchoolSalina Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wickliffe Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Noble County.

—Please choose an option—Berryhill Public SchoolsFrontier Public SchoolsMorrison Public SchoolPerry Public School

Please select which school this child attends.

—Please choose an option—Billings ElementaryBillings High SchoolOther

Please select which school this child attends.

—Please choose an option—Frontier Elementary SchoolFrontier High SchoolOther

Please select which school this child attends.

—Please choose an option—Morrison Elementary SchoolMorrison High SchoolMorrison Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Perry High SchoolPerry Junior High SchoolPerry Lower Elementary SchoolPerry Upper Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Nowata County.

—Please choose an option—Nowata Public SchoolOklahoma Union Public SchoolSouth Coffeyville Public School

Please select which school this child attends.

—Please choose an option—Nowata Alternative District I-40Nowata Elementary SchoolNowata High SchoolNowata Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oklahoma Union ElementaryOklahoma Union High SchoolOklahoma Union Middle SchoolOther

Please select which school this child attends.

—Please choose an option—South Coffeyville Elementary SchoolSouth Coffeyville High SchoolSouth Coffeyville Middle SchoolOther

If Other, please type school name below.

Please select a school district in Osage County.

—Please choose an option—Barnsdall Public SchoolsHominy Public SchoolsPawhuska Public SchoolPrue Public SchoolSkiatook Public SchoolsShidler Public SchoolWoodland Public SchoolWynona Public School

Please select which school this child attends.

—Please choose an option—Barnsdall Elementary SchoolBarnsdall High SchoolBarnsdall Junior HighOther

Please select which school this child attends.

—Please choose an option—Hominy Early Childhood CenterHominy High SchoolHominy Middle SchoolHorace Mann Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Indian Camp Elementary SchoolPawhuska Elementary SchoolPawhuska High SchoolPawhuska Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Prue Elementary SchoolSouth Coffeyville High SchoolPrue High SchoolOther

Please select which school this child attends.

—Please choose an option—Shidler High SchoolSouth Coffeyville High SchoolShidler Middle SchoolWard Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Woodland Elementary SchoolWoodland High SchoolWoodland Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Wynona Elementary SchoolWynona High SchoolOther

Please select which school this child attends.

—Please choose an option—Marrs Elementary SchoolNewman Middle SchoolSkiatook ElementarySkiatook High SchoolSkiatook Middle SchoolSkiatook Intermediate Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Ottawa County.

—Please choose an option—Adair Public SchoolsCleora Public SchoolsCommerce Public SchoolsFairland Public SchoolsMiami Public SchoolQuapaw Public SchoolTurkey Ford Public SchoolWyandotte Public School

Please select which school this child attends.

—Please choose an option—Afton Elementary SchoolAfton High SchoolOther

Please select which school this child attends.

—Please choose an option—Cleora ElementaryOther

Please select which school this child attends.

—Please choose an option—Alexander Elementary SchoolCommerce High SchoolCommerce Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Fairland Elementary SchoolFairland High SchoolFairland Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Miami AcademyMiami High SchoolMiami Jr High SchoolNichols Elementary SchoolWashington Elementary SchoolWilson Elementary SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Quapaw Elementary SchoolQuapaw Elementary SchoolQuapaw Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wyandotte Elementary SchoolWyandotte Junior Senior High SchoolOther

Please select which school this child attends.

—Please choose an option—Turkey Ford Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Pawnee County.

—Please choose an option—Cleveland Public SchoolsJennings Public SchoolsMannford Public SchoolsPawnee Public Schools

Please select which school this child attends.

—Please choose an option—Cleveland High SchoolCleveland Intermediate Elementary SchoolCleveland Middle SchoolCleveland Primary Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jennings Public SchoolOther

Please select which school this child attends.

—Please choose an option—Mannford Elementary SchoolMannford High SchoolMannford Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Pawnee Elementary SchoolPawnee High SchoolPawnee Middle SchoolOther

If Other, please type school name below.

Please select a school district in Payne County.

—Please choose an option—Cushing Public SchoolsGlencoe Public SchoolsOak Grove Public SchoolPerkins-Tryon Public SchoolRipley Public SchoolStillwater Public SchoolYale Public Schools

Please select which school this child attends.

—Please choose an option—Cushing High SchoolCushing Lower Elementary SchoolCushing Middle SchoolCushing Upper Elementary SchoolCushing Wilson SchoolOther

Please select which school this child attends.

—Please choose an option—Glencoe Elementary SchoolGlencoe High SchoolOther

Please select which school this child attends.

—Please choose an option—Oak Grove Public SchoolOther

Please select which school this child attends.

—Please choose an option—Perkins-Tryon Elementary SchoolPerkins-Tryon High SchoolPerkins-Tryon Intermediate SchoolPerkins-Tryon Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Ripley Elementary SchoolRipley High SchoolOther

Please select which school this child attends.

—Please choose an option—Highland Park Elementary SchoolLincoln AcademyRichmond Elementary SchoolSangre Ridge Elementary SchoolSkyline Elementary SchoolStillwater High SchoolStillwater Jr. High SchoolStillwater Middle SchoolWestwood Elementary SchoolWill Rogers Elementary SchoolStillwater Pioneer Virtual AcademyOther

Please select which school this child attends.

—Please choose an option—Yale Elementary SchoolYale High SchoolYale Middle SchoolOther

If Other, please type school name below.

Please select a school district in Rogers County.

—Please choose an option—Catoosa Public SchoolsClaremore Public SchoolsCollinsville Public SchoolsFoyil Public SchoolsInola Public SchoolsOologah Public SchoolOwasso Public SchoolSequoyah Public SchoolsVerdigris Public Schools

Please select which school this child attends.

—Please choose an option—Art Goad ElementaryCatoosa High SchoolChelsea High SchoolChelsea Middle SchoolCherokee Elementary SchoolHelen Paul Learning CenterWells Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Catalayah Elementary SchoolClaremont Elementary SchoolClaremore High SchoolJustus-Tiawah North CampusJustus-Tiawah South CampusRoosa Elementary SchoolWestside Elementary SchoolWill Rogers Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—Foyil Elementary SchoolFoyil High SchoolFoyil Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Inola Elementary SchoolInola High SchoolInola Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oologah-Talala High SchoolOologah-Talala Lower Elementary SchoolOologah-Talala Middle SchoolOologah-Talala Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Pamela Hodson ElementaryStone Canyon ElementaryOther

Please select which school this child attends.

—Please choose an option—Sequoyah Elementary SchoolSequoyah High SchoolSequoyah Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Verdigris Elementary SchoolVerdigris High SchoolVerdigris Junior High SchoolVerdigris Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Collinsville High SchoolCollinsville Middle SchoolCollinsville Upper Elementary SchoolHerald Lower ElementaryJanice K. Pollard ECCWilson 6th Grade CenterOther

If Other, please type school name below.

Please select a school district in Tulsa County.

—Please choose an option—Berryhill Public SchoolsBixby Public SchoolsBroken Arrow Public SchoolsGlenpool Public SchoolsJenks Public SchoolsOwasso Public SchoolPrivateSand Springs Public SchoolSperry Public SchoolsSummit Christian AcademyTulsa Public SchoolUnion Public Schools

Please select which school this child attends.

—Please choose an option—Berryhill ElementaryBerryhill High SchoolBerryhill Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Bixby 9th Grade CenterBixby Alternative EducationBixby Central ElementaryBixby Central Intermediate SchoolBixby East ElementaryBixby East Intermediate SchoolBixby High SchoolBixby Middle SchoolBixby North ElementaryBixby North Intermediate SchoolBixby West ElementaryBixby West Intermediate SchoolOther

Please select which school this child attends.

—Please choose an option—Arrow Springs Early ChildhoodArrowhead ElementaryAspen Creek Early ChildhoodAspen Creek ElementaryBA Options Academy AlternativeBroken Arrow High SchoolCentennial Middle SchoolChilders Middle SchoolCountry Lane IntermediateCountry Lane PrimaryCreekwood Early ChildhoodCreekwood ElementaryFreshman AcademyHighland Park ElementaryLeisure Park ElementaryLiberty ElementaryLynn Wood ElementaryOak Crest ElementaryOliver Middle SchoolOneta Ridge Middle SchoolPark Lane Early ChildhoodRhoades ElementaryRosewood ElementarySequoyah Middle SchoolSpring Creek ElementaryTimber Ridge ElementaryVandever ElementaryVanguard AcademyVirtual AcademyWolf Creek ElementaryOther

Please select which school this child attends.

—Please choose an option—Glenpool ElementaryGlenpool High SchoolGlenpool IntermediateGlenpool Lower ElementaryGlenpool Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Jenks Alternative CenterJenks East ElementaryJenks East IntermediateJenks Freshman AcademyJenks High SchoolJenks Middle SchoolJenks Northwest ElementaryJenks Southeast ElementaryJenks West ElementaryJenks West IntermediateOther

Please select which school this child attends.

—Please choose an option—Smith Elementary SchoolAtor Elementary SchoolBailey Elementary SchoolBarnes Elementary SchoolHudson ElementaryMills Elementary SchoolMorrow Elementary SchoolOwasso 6th Grade CenterOwasso 7th Grade CenterOwasso 8th Grade CenterOwasso High SchoolOwasso Northeast Elementary SchoolRam Academy - AlternativeOther

Please select which school this child attends.

—Please choose an option—Bishop Kelly High SchoolOther

Please select which school this child attends.

—Please choose an option—Sand Springs 6th Grade CenterSand Springs Angus Vallen ElementarySand Springs Charles Page High SchoolSand Springs Clyde Boyd Middle SchoolSand Springs CPHS Freshman AcademySand Springs Early Childhood Education CenterSand Springs Garfield STEAM AcademySand Springs Limestone Technology AcademySand Springs Northwest Fine Arts AcademySand Springs Page Academy Alternative High SchoolSand Springs Pratt ElementaryOther

Please select which school this child attends.

—Please choose an option—Sperry Elementary SchoolSperry High SchoolSperry Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Summit Christian AcademyOther

Please select which school this child attends.

—Please choose an option—Memorial High SchoolThoreau Demonstration Academy Middle SchoolTulsa - East Central High SchoolWhitman ElementaryBell ElementaryBooker T. Washington High SchoolBurroughs ElementaryCAP Tulsa (Pre-K & Early Childhood)Carnegie ElementaryCarver Middle SchoolCelia Clinton ElementaryCentral High SchoolCentral Middle SchoolClinton West ElementaryCollege Bound Academy ElementaryCollegiate Hall Elementary & MiddleCooper ElementaryCornerstone (Pre-K & Early Childhood)Council Oak ElementaryCrosstown (Pre-K & Early Childhood)Daniel Webster High SchoolDaniel Webster Middle SchoolDisney ElementaryDolores Huerta ElementaryEast Central Junior High SchoolEdison Prepatory High SchoolEdison Prepatory Middle SchoolEducare (Pre-K & Early Childhood)Eisenhower International Elementary MagnetEliot ElementaryEmerson ElementaryEugene Field ElementaryFelicitas Mendez International ElementaryGreenwood Leadership Academy ElementaryGrissom ElementaryHale High SchoolHamilton ElementaryHawthorne ElementaryHenry Zarrow International Elementary MagnetHoover ElementaryJohn Hope Franklin ElementaryKendall-Whittier ElementaryKerr Elementary SchoolKey ElementaryKIPP Tulsa University Prep High SchoolLanier ElementaryLewis and Clark ElementaryLindbergh ElementaryMacArthur ElementaryMarshall ElementaryMayo Demonstration Elementary (Magnet)McClure ElementaryMcKinely ElementaryMcLain High SchoolMitchell ElementaryMonroe Demonstration Academy Middle SchoolNorth Star Academy High - AlternativeOwen ElementaryPatrick Henry ElementaryPeary ElementaryPhoenix Rising High School - AlternativeRobertson ElementarySalk ElementarySequoyah ElementarySkelly ElementarySpringdale ElementaryStreet School High School - AlternativeTulsa Anderson ElementaryTulsa Honor Academy High SchoolTulsa Honor Academy Middle SchoolTulsa Legacy Charter Primary Academy (Elem)Tulsa Legacy Charter Upper Academy (Middle)Tulsa MET High School - AlternativeTulsa MET Middle - AlternativeTulsa School of Arts and Sciences High SchoolTulsa Tech Career AcademyTulsa Virtual Academy ElementaryTulsa Virtual Academy HighTulsa Virtual Academy MiddleUnity Learning Academy ElementaryWayman Tisdale Fine Arts Academy ElementaryWill Rogers College High SchoolWill Rogers College Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Union 8th Grade Center6th & 7th Grade CenterBoevers ElementaryBroken Arrow Anderson ElementaryCedar Ridge ElementaryDarnaby ElementaryEllen Ochoa ElementaryGrove ElementaryJarman ElementaryJefferson ElementaryMcAuliffe ElementaryMoore ElementaryPeters ElementaryRosa Parks Early ChildhoodRosa Parks ElementaryRoy Clark ElementaryUHS Freshman AcademyUnion Alternative SchoolUnion High SchoolOther

If Other, please type school name below.

Please select a school district in Washington County.

—Please choose an option—Bartlesville Public SchoolsCaney Valley Public SchoolsCopan Public SchoolsDewey Public Schools

Please select which school this child attends.

—Please choose an option—Bartlesville High SchoolMadison Middle SchoolRanch Heights Elementary SchoolRichard Kane Elementary SchoolWayside Elementary SchoolWoodrow Wilson ElementaryJane Phillips Elementary SchoolHoover Elementary SchoolCentral Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Caney Valley Elementary School - OchelataCaney Valley High SchoolOther

Please select which school this child attends.

—Please choose an option—Copan High SchoolOther

Please select which school this child attends.

—Please choose an option—Dewey Elementary SchoolDewey High SchoolDewey Middle SchoolOther

If Other, please type school name below.

Child's grade

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

Medicaid (SoonerCare) Member Number

Medicare Member Number

Please specify other insurance

Parent/guardian name*

Relationship to child

Primary phone*

Secondary phone

Email

Name*

Relationship to child being referred*

Phone*

Email

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

Date of referral*

Legal name of individual being referred*

Birth date*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Primary phone*

Secondary phone

Street

City

State

Zip Code

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

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

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

Medicaid (SoonerCare) Member Number

Medicare Member Number

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

Name*

Relationship to individual being referred*

Phone*

Email

Date of referral*

Legal name of child being referred*

Birth date*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Street

City

State

Zip Code

Which county is this referral for?*

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

Please select a school district in Craig County.

—Please choose an option—Bluejacket Public SchoolsCowboy Junction Christian SchoolKetchum Public SchoolsVinita Public SchoolWelch Public SchoolWhite Oak Public School

Please select which school this child attends.

—Please choose an option—Bluejacket Elementary SchoolBluejacket High SchoolBluejacket Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Cowboy Junction SchoolOther

Please select which school this child attends.

—Please choose an option—Ketchum Elementary SchoolKetchum High SchoolKetchum Middle SchoolKetchum Seventh Day Adventist AcademyOther

Please select which school this child attends.

—Please choose an option—Hall-Halsell Elementary SchoolVinita High SchoolVinita Middle SchoolWill Rogers Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Welch Elementary SchoolWelch High SchoolWelch Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—White Oak Elementary SchoolWhite Oak High SchoolOther

If Other, please type school name below.

Please select a school district in Delaware County.

—Please choose an option—Christian Hills Christian SchoolColcord Public SchoolsGrove Public SchoolsJay Public SchoolsKansas Public SchoolsKenwood Public SchoolsLeach Public SchoolsMoseley Public SchoolOaks - Mission Public SchoolWestville Public School

Please select which school this child attends.

—Please choose an option—Cookson Hills Christian SchoolOther

Please select which school this child attends.

—Please choose an option—Colcord Alternative EducationColcord Elementary SchoolColcord Head StartColcord High SchoolColcord Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Grove Alternative SchoolGrove Early Childhood CenterGrove Head StartGrove High SchoolGrove Lower Elementary SchoolGrove Middle SchoolGrove Upper Elementary SchoolGrove Virtual SchoolOther

Please select which school this child attends.

—Please choose an option—Jay Alternative EducationJay Cherokee Nation Head StartJay Elementary SchoolJay Head StartJay High SchoolJay Lower Elementary SchoolJay Middle SchoolJay Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Kansas Alternative SchoolKansas Elementary SchoolKansas Head StartKansas High SchoolKansas Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Kenwood Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Leach Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Moseley Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Oaks-Mission Elementary SchoolOaks-Mission Middle SchoolOaks-Missoin High SchoolOther

Please select which school this child attends.

—Please choose an option—Westville High SchoolWestville Skelly Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Kay County.

—Please choose an option—Blackwell Public SchoolsNewkirk Public SchoolPonca City Public SchoolTonkawa Public School

Please select which school this child attends.

—Please choose an option—Blackwell Elementary SchoolBlackwell Head StartBlackwell High SchoolBlackwell Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Newkirk Braman ElementaryNewkirk High SchoolNewkirk Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Garfield Elementary SchoolLiberty Elementary SchoolLincoln Elementary SchoolPonca City Alternative Wildcate AcademyPonca City East Middle SchoolPonca City Head StartPonca City High SchoolPonca City Virtual AcademyPonca City West Middle SchoolRoosevelt Elementary SchoolTrout Elementary SchoolUnion Elementary SchoolWashington Pre K Center SchoolWoodlands Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Tonkawa Elementary SchoolTonkawa HIgh SchoolTonkawa Middle SchoolOther

If Other, please type school name below.

Please select a school district in Mayes County.

—Please choose an option—Adair Public SchoolsChouteau - Mazie Public SchoolsLocust Grove Public SchoolsOsage Public SchoolPryor Public SchoolSalina Public SchoolWickliffe Public School

Please select which school this child attends.

—Please choose an option—Adair High SchoolAdair Middle SchoolBernita Hughes Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Chouteau Early Learning CenterChouteau Elementary SchoolChouteau-Mazie High SchoolChouteau-Mazie Middle SchoolMazie Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Locust Grove Early Learning CenterLocust Grove High SchoolLocust Grove Middle SchoolLocust Grove Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Osage Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jefferson Elementary SchoolLincoln Elementary SchoolPryor High SchoolPryor Junior High SchoolPryor Middle SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Salina Elementary SchoolSalina High SchoolSalina Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wickliffe Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Noble County.

—Please choose an option—Berryhill Public SchoolsFrontier Public SchoolsMorrison Public SchoolPerry Public School

Please select which school this child attends.

—Please choose an option—Billings ElementaryBillings High SchoolOther

Please select which school this child attends.

—Please choose an option—Frontier Elementary SchoolFrontier High SchoolOther

Please select which school this child attends.

—Please choose an option—Morrison Elementary SchoolMorrison High SchoolMorrison Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Perry High SchoolPerry Junior High SchoolPerry Lower Elementary SchoolPerry Upper Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Nowata County.

—Please choose an option—Nowata Public SchoolOklahoma Union Public SchoolSouth Coffeyville Public School

Please select which school this child attends.

—Please choose an option—Nowata Alternative District I-40Nowata Elementary SchoolNowata High SchoolNowata Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oklahoma Union ElementaryOklahoma Union High SchoolOklahoma Union Middle SchoolOther

Please select which school this child attends.

—Please choose an option—South Coffeyville Elementary SchoolSouth Coffeyville High SchoolSouth Coffeyville Middle SchoolOther

If Other, please type school name below.

Please select a school district in Osage County.

—Please choose an option—Barnsdall Public SchoolsHominy Public SchoolsPawhuska Public SchoolPrue Public SchoolSkiatook Public SchoolsShidler Public SchoolWoodland Public SchoolWynona Public School

Please select which school this child attends.

—Please choose an option—Barnsdall Elementary SchoolBarnsdall High SchoolBarnsdall Junior HighOther

Please select which school this child attends.

—Please choose an option—Hominy Early Childhood CenterHominy High SchoolHominy Middle SchoolHorace Mann Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Indian Camp Elementary SchoolPawhuska Elementary SchoolPawhuska High SchoolPawhuska Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Prue Elementary SchoolSouth Coffeyville High SchoolPrue High SchoolOther

Please select which school this child attends.

—Please choose an option—Shidler High SchoolSouth Coffeyville High SchoolShidler Middle SchoolWard Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Woodland Elementary SchoolWoodland High SchoolWoodland Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Wynona Elementary SchoolWynona High SchoolOther

Please select which school this child attends.

—Please choose an option—Marrs Elementary SchoolNewman Middle SchoolSkiatook ElementarySkiatook High SchoolSkiatook Middle SchoolSkiatook Intermediate Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Ottawa County.

—Please choose an option—Adair Public SchoolsCleora Public SchoolsCommerce Public SchoolsFairland Public SchoolsMiami Public SchoolQuapaw Public SchoolTurkey Ford Public SchoolWyandotte Public School

Please select which school this child attends.

—Please choose an option—Afton Elementary SchoolAfton High SchoolOther

Please select which school this child attends.

—Please choose an option—Cleora ElementaryOther

Please select which school this child attends.

—Please choose an option—Alexander Elementary SchoolCommerce High SchoolCommerce Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Fairland Elementary SchoolFairland High SchoolFairland Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Miami AcademyMiami High SchoolMiami Jr High SchoolNichols Elementary SchoolWashington Elementary SchoolWilson Elementary SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Quapaw Elementary SchoolQuapaw Elementary SchoolQuapaw Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wyandotte Elementary SchoolWyandotte Junior Senior High SchoolOther

Please select which school this child attends.

—Please choose an option—Turkey Ford Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Pawnee County.

—Please choose an option—Cleveland Public SchoolsJennings Public SchoolsMannford Public SchoolsPawnee Public Schools

Please select which school this child attends.

—Please choose an option—Cleveland High SchoolCleveland Intermediate Elementary SchoolCleveland Middle SchoolCleveland Primary Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jennings Public SchoolOther

Please select which school this child attends.

—Please choose an option—Mannford Elementary SchoolMannford High SchoolMannford Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Pawnee Elementary SchoolPawnee High SchoolPawnee Middle SchoolOther

If Other, please type school name below.

Please select a school district in Payne County.

—Please choose an option—Cushing Public SchoolsGlencoe Public SchoolsOak Grove Public SchoolPerkins-Tryon Public SchoolRipley Public SchoolStillwater Public SchoolYale Public Schools

Please select which school this child attends.

—Please choose an option—Cushing High SchoolCushing Lower Elementary SchoolCushing Middle SchoolCushing Upper Elementary SchoolCushing Wilson SchoolOther

Please select which school this child attends.

—Please choose an option—Glencoe Elementary SchoolGlencoe High SchoolOther

Please select which school this child attends.

—Please choose an option—Oak Grove Public SchoolOther

Please select which school this child attends.

—Please choose an option—Perkins-Tryon Elementary SchoolPerkins-Tryon High SchoolPerkins-Tryon Intermediate SchoolPerkins-Tryon Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Ripley Elementary SchoolRipley High SchoolOther

Please select which school this child attends.

—Please choose an option—Highland Park Elementary SchoolLincoln AcademyRichmond Elementary SchoolSangre Ridge Elementary SchoolSkyline Elementary SchoolStillwater High SchoolStillwater Jr. High SchoolStillwater Middle SchoolWestwood Elementary SchoolWill Rogers Elementary SchoolStillwater Pioneer Virtual AcademyOther

Please select which school this child attends.

—Please choose an option—Yale Elementary SchoolYale High SchoolYale Middle SchoolOther

If Other, please type school name below.

Please select a school district in Rogers County.

—Please choose an option—Catoosa Public SchoolsClaremore Public SchoolsCollinsville Public SchoolsFoyil Public SchoolsInola Public SchoolsOologah Public SchoolOwasso Public SchoolSequoyah Public SchoolsVerdigris Public Schools

Please select which school this child attends.

—Please choose an option—Art Goad ElementaryCatoosa High SchoolChelsea High SchoolChelsea Middle SchoolCherokee Elementary SchoolHelen Paul Learning CenterWells Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Catalayah Elementary SchoolClaremont Elementary SchoolClaremore High SchoolJustus-Tiawah North CampusJustus-Tiawah South CampusRoosa Elementary SchoolWestside Elementary SchoolWill Rogers Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—Foyil Elementary SchoolFoyil High SchoolFoyil Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Inola Elementary SchoolInola High SchoolInola Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oologah-Talala High SchoolOologah-Talala Lower Elementary SchoolOologah-Talala Middle SchoolOologah-Talala Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Pamela Hodson ElementaryStone Canyon ElementaryOther

Please select which school this child attends.

—Please choose an option—Sequoyah Elementary SchoolSequoyah High SchoolSequoyah Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Verdigris Elementary SchoolVerdigris High SchoolVerdigris Junior High SchoolVerdigris Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Collinsville High SchoolCollinsville Middle SchoolCollinsville Upper Elementary SchoolHerald Lower ElementaryJanice K. Pollard ECCWilson 6th Grade CenterOther

If Other, please type school name below.

Please select a school district in Tulsa County.

—Please choose an option—Berryhill Public SchoolsBixby Public SchoolsBroken Arrow Public SchoolsGlenpool Public SchoolsJenks Public SchoolsOwasso Public SchoolPrivateSand Springs Public SchoolSperry Public SchoolsSummit Christian AcademyTulsa Public SchoolUnion Public Schools

Please select which school this child attends.

—Please choose an option—Berryhill ElementaryBerryhill High SchoolBerryhill Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Bixby 9th Grade CenterBixby Alternative EducationBixby Central ElementaryBixby Central Intermediate SchoolBixby East ElementaryBixby East Intermediate SchoolBixby High SchoolBixby Middle SchoolBixby North ElementaryBixby North Intermediate SchoolBixby West ElementaryBixby West Intermediate SchoolOther

Please select which school this child attends.

—Please choose an option—Arrow Springs Early ChildhoodArrowhead ElementaryAspen Creek Early ChildhoodAspen Creek ElementaryBA Options Academy AlternativeBroken Arrow High SchoolCentennial Middle SchoolChilders Middle SchoolCountry Lane IntermediateCountry Lane PrimaryCreekwood Early ChildhoodCreekwood ElementaryFreshman AcademyHighland Park ElementaryLeisure Park ElementaryLiberty ElementaryLynn Wood ElementaryOak Crest ElementaryOliver Middle SchoolOneta Ridge Middle SchoolPark Lane Early ChildhoodRhoades ElementaryRosewood ElementarySequoyah Middle SchoolSpring Creek ElementaryTimber Ridge ElementaryVandever ElementaryVanguard AcademyVirtual AcademyWolf Creek ElementaryOther

Please select which school this child attends.

—Please choose an option—Glenpool ElementaryGlenpool High SchoolGlenpool IntermediateGlenpool Lower ElementaryGlenpool Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Jenks Alternative CenterJenks East ElementaryJenks East IntermediateJenks Freshman AcademyJenks High SchoolJenks Middle SchoolJenks Northwest ElementaryJenks Southeast ElementaryJenks West ElementaryJenks West IntermediateOther

Please select which school this child attends.

—Please choose an option—Smith Elementary SchoolAtor Elementary SchoolBailey Elementary SchoolBarnes Elementary SchoolHudson ElementaryMills Elementary SchoolMorrow Elementary SchoolOwasso 6th Grade CenterOwasso 7th Grade CenterOwasso 8th Grade CenterOwasso High SchoolOwasso Northeast Elementary SchoolRam Academy - AlternativeOther

Please select which school this child attends.

—Please choose an option—Bishop Kelly High SchoolOther

Please select which school this child attends.

—Please choose an option—Sand Springs 6th Grade CenterSand Springs Angus Vallen ElementarySand Springs Charles Page High SchoolSand Springs Clyde Boyd Middle SchoolSand Springs CPHS Freshman AcademySand Springs Early Childhood Education CenterSand Springs Garfield STEAM AcademySand Springs Limestone Technology AcademySand Springs Northwest Fine Arts AcademySand Springs Page Academy Alternative High SchoolSand Springs Pratt ElementaryOther

Please select which school this child attends.

—Please choose an option—Sperry Elementary SchoolSperry High SchoolSperry Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Summit Christian AcademyOther

Please select which school this child attends.

—Please choose an option—Memorial High SchoolThoreau Demonstration Academy Middle SchoolTulsa - East Central High SchoolWhitman ElementaryBell ElementaryBooker T. Washington High SchoolBurroughs ElementaryCAP Tulsa (Pre-K & Early Childhood)Carnegie ElementaryCarver Middle SchoolCelia Clinton ElementaryCentral High SchoolCentral Middle SchoolClinton West ElementaryCollege Bound Academy ElementaryCollegiate Hall Elementary & MiddleCooper ElementaryCornerstone (Pre-K & Early Childhood)Council Oak ElementaryCrosstown (Pre-K & Early Childhood)Daniel Webster High SchoolDaniel Webster Middle SchoolDisney ElementaryDolores Huerta ElementaryEast Central Junior High SchoolEdison Prepatory High SchoolEdison Prepatory Middle SchoolEducare (Pre-K & Early Childhood)Eisenhower International Elementary MagnetEliot ElementaryEmerson ElementaryEugene Field ElementaryFelicitas Mendez International ElementaryGreenwood Leadership Academy ElementaryGrissom ElementaryHale High SchoolHamilton ElementaryHawthorne ElementaryHenry Zarrow International Elementary MagnetHoover ElementaryJohn Hope Franklin ElementaryKendall-Whittier ElementaryKerr Elementary SchoolKey ElementaryKIPP Tulsa University Prep High SchoolLanier ElementaryLewis and Clark ElementaryLindbergh ElementaryMacArthur ElementaryMarshall ElementaryMayo Demonstration Elementary (Magnet)McClure ElementaryMcKinely ElementaryMcLain High SchoolMitchell ElementaryMonroe Demonstration Academy Middle SchoolNorth Star Academy High - AlternativeOwen ElementaryPatrick Henry ElementaryPeary ElementaryPhoenix Rising High School - AlternativeRobertson ElementarySalk ElementarySequoyah ElementarySkelly ElementarySpringdale ElementaryStreet School High School - AlternativeTulsa Anderson ElementaryTulsa Honor Academy High SchoolTulsa Honor Academy Middle SchoolTulsa Legacy Charter Primary Academy (Elem)Tulsa Legacy Charter Upper Academy (Middle)Tulsa MET High School - AlternativeTulsa MET Middle - AlternativeTulsa School of Arts and Sciences High SchoolTulsa Tech Career AcademyTulsa Virtual Academy ElementaryTulsa Virtual Academy HighTulsa Virtual Academy MiddleUnity Learning Academy ElementaryWayman Tisdale Fine Arts Academy ElementaryWill Rogers College High SchoolWill Rogers College Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Union 8th Grade Center6th & 7th Grade CenterBoevers ElementaryBroken Arrow Anderson ElementaryCedar Ridge ElementaryDarnaby ElementaryEllen Ochoa ElementaryGrove ElementaryJarman ElementaryJefferson ElementaryMcAuliffe ElementaryMoore ElementaryPeters ElementaryRosa Parks Early ChildhoodRosa Parks ElementaryRoy Clark ElementaryUHS Freshman AcademyUnion Alternative SchoolUnion High SchoolOther

If Other, please type school name below.

Please select a school district in Washington County.

—Please choose an option—Bartlesville Public SchoolsCaney Valley Public SchoolsCopan Public SchoolsDewey Public Schools

Please select which school this child attends.

—Please choose an option—Bartlesville High SchoolMadison Middle SchoolRanch Heights Elementary SchoolRichard Kane Elementary SchoolWayside Elementary SchoolWoodrow Wilson ElementaryJane Phillips Elementary SchoolHoover Elementary SchoolCentral Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Caney Valley Elementary School - OchelataCaney Valley High SchoolOther

Please select which school this child attends.

—Please choose an option—Copan High SchoolOther

Please select which school this child attends.

—Please choose an option—Dewey Elementary SchoolDewey High SchoolDewey Middle SchoolOther

If Other, please type school name below.

Child's grade

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

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

Email

Name*

Relationship to child being referred*

Phone*

Email

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.

Name*

Relationship to child being referred*

Phone*

Email

Date of referral*

Legal name of individual being referred*

Birth date*

Gender *

—Please choose an option—MaleFemaleNonbinaryPrefer not to sayPrefer to self describe

Prefer to self describe:

Primary phone*

Secondary phone

Street

City

State

Zip Code

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

—Please choose an option—CraigDelawareKayMayesNobleNowataOsageOttawaPawneePayneRogersTulsaWashington

Please select a school district in Craig County.

—Please choose an option—Bluejacket Public SchoolsCowboy Junction Christian SchoolKetchum Public SchoolsVinita Public SchoolWelch Public SchoolWhite Oak Public School

Please select which school this child attends.

—Please choose an option—Bluejacket Elementary SchoolBluejacket High SchoolBluejacket Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Cowboy Junction SchoolOther

Please select which school this child attends.

—Please choose an option—Ketchum Elementary SchoolKetchum High SchoolKetchum Middle SchoolKetchum Seventh Day Adventist AcademyOther

Please select which school this child attends.

—Please choose an option—Hall-Halsell Elementary SchoolVinita High SchoolVinita Middle SchoolWill Rogers Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Welch Elementary SchoolWelch High SchoolWelch Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—White Oak Elementary SchoolWhite Oak High SchoolOther

If Other, please type school name below.

Please select a school district in Delaware County.

—Please choose an option—Christian Hills Christian SchoolColcord Public SchoolsGrove Public SchoolsJay Public SchoolsKansas Public SchoolsKenwood Public SchoolsLeach Public SchoolsMoseley Public SchoolOaks - Mission Public SchoolWestville Public School

Please select which school this child attends.

—Please choose an option—Cookson Hills Christian SchoolOther

Please select which school this child attends.

—Please choose an option—Colcord Alternative EducationColcord Elementary SchoolColcord Head StartColcord High SchoolColcord Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Grove Alternative SchoolGrove Early Childhood CenterGrove Head StartGrove High SchoolGrove Lower Elementary SchoolGrove Middle SchoolGrove Upper Elementary SchoolGrove Virtual SchoolOther

Please select which school this child attends.

—Please choose an option—Jay Alternative EducationJay Cherokee Nation Head StartJay Elementary SchoolJay Head StartJay High SchoolJay Lower Elementary SchoolJay Middle SchoolJay Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Kansas Alternative SchoolKansas Elementary SchoolKansas Head StartKansas High SchoolKansas Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Kenwood Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Leach Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Moseley Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Oaks-Mission Elementary SchoolOaks-Mission Middle SchoolOaks-Missoin High SchoolOther

Please select which school this child attends.

—Please choose an option—Westville High SchoolWestville Skelly Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Kay County.

—Please choose an option—Blackwell Public SchoolsNewkirk Public SchoolPonca City Public SchoolTonkawa Public School

Please select which school this child attends.

—Please choose an option—Blackwell Elementary SchoolBlackwell Head StartBlackwell High SchoolBlackwell Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Newkirk Braman ElementaryNewkirk High SchoolNewkirk Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Garfield Elementary SchoolLiberty Elementary SchoolLincoln Elementary SchoolPonca City Alternative Wildcate AcademyPonca City East Middle SchoolPonca City Head StartPonca City High SchoolPonca City Virtual AcademyPonca City West Middle SchoolRoosevelt Elementary SchoolTrout Elementary SchoolUnion Elementary SchoolWashington Pre K Center SchoolWoodlands Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Tonkawa Elementary SchoolTonkawa HIgh SchoolTonkawa Middle SchoolOther

If Other, please type school name below.

Please select a school district in Mayes County.

—Please choose an option—Adair Public SchoolsChouteau - Mazie Public SchoolsLocust Grove Public SchoolsOsage Public SchoolPryor Public SchoolSalina Public SchoolWickliffe Public School

Please select which school this child attends.

—Please choose an option—Adair High SchoolAdair Middle SchoolBernita Hughes Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Chouteau Early Learning CenterChouteau Elementary SchoolChouteau-Mazie High SchoolChouteau-Mazie Middle SchoolMazie Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Locust Grove Early Learning CenterLocust Grove High SchoolLocust Grove Middle SchoolLocust Grove Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Osage Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jefferson Elementary SchoolLincoln Elementary SchoolPryor High SchoolPryor Junior High SchoolPryor Middle SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Salina Elementary SchoolSalina High SchoolSalina Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wickliffe Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Noble County.

—Please choose an option—Berryhill Public SchoolsFrontier Public SchoolsMorrison Public SchoolPerry Public School

Please select which school this child attends.

—Please choose an option—Billings ElementaryBillings High SchoolOther

Please select which school this child attends.

—Please choose an option—Frontier Elementary SchoolFrontier High SchoolOther

Please select which school this child attends.

—Please choose an option—Morrison Elementary SchoolMorrison High SchoolMorrison Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Perry High SchoolPerry Junior High SchoolPerry Lower Elementary SchoolPerry Upper Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Nowata County.

—Please choose an option—Nowata Public SchoolOklahoma Union Public SchoolSouth Coffeyville Public School

Please select which school this child attends.

—Please choose an option—Nowata Alternative District I-40Nowata Elementary SchoolNowata High SchoolNowata Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oklahoma Union ElementaryOklahoma Union High SchoolOklahoma Union Middle SchoolOther

Please select which school this child attends.

—Please choose an option—South Coffeyville Elementary SchoolSouth Coffeyville High SchoolSouth Coffeyville Middle SchoolOther

If Other, please type school name below.

Please select a school district in Osage County.

—Please choose an option—Barnsdall Public SchoolsHominy Public SchoolsPawhuska Public SchoolPrue Public SchoolSkiatook Public SchoolsShidler Public SchoolWoodland Public SchoolWynona Public School

Please select which school this child attends.

—Please choose an option—Barnsdall Elementary SchoolBarnsdall High SchoolBarnsdall Junior HighOther

Please select which school this child attends.

—Please choose an option—Hominy Early Childhood CenterHominy High SchoolHominy Middle SchoolHorace Mann Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Indian Camp Elementary SchoolPawhuska Elementary SchoolPawhuska High SchoolPawhuska Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Prue Elementary SchoolSouth Coffeyville High SchoolPrue High SchoolOther

Please select which school this child attends.

—Please choose an option—Shidler High SchoolSouth Coffeyville High SchoolShidler Middle SchoolWard Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Woodland Elementary SchoolWoodland High SchoolWoodland Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Wynona Elementary SchoolWynona High SchoolOther

Please select which school this child attends.

—Please choose an option—Marrs Elementary SchoolNewman Middle SchoolSkiatook ElementarySkiatook High SchoolSkiatook Middle SchoolSkiatook Intermediate Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Ottawa County.

—Please choose an option—Adair Public SchoolsCleora Public SchoolsCommerce Public SchoolsFairland Public SchoolsMiami Public SchoolQuapaw Public SchoolTurkey Ford Public SchoolWyandotte Public School

Please select which school this child attends.

—Please choose an option—Afton Elementary SchoolAfton High SchoolOther

Please select which school this child attends.

—Please choose an option—Cleora ElementaryOther

Please select which school this child attends.

—Please choose an option—Alexander Elementary SchoolCommerce High SchoolCommerce Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Fairland Elementary SchoolFairland High SchoolFairland Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Miami AcademyMiami High SchoolMiami Jr High SchoolNichols Elementary SchoolWashington Elementary SchoolWilson Elementary SchoolRoosevelt Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Quapaw Elementary SchoolQuapaw Elementary SchoolQuapaw Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Wyandotte Elementary SchoolWyandotte Junior Senior High SchoolOther

Please select which school this child attends.

—Please choose an option—Turkey Ford Elementary SchoolOther

If Other, please type school name below.

Please select a school district in Pawnee County.

—Please choose an option—Cleveland Public SchoolsJennings Public SchoolsMannford Public SchoolsPawnee Public Schools

Please select which school this child attends.

—Please choose an option—Cleveland High SchoolCleveland Intermediate Elementary SchoolCleveland Middle SchoolCleveland Primary Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Jennings Public SchoolOther

Please select which school this child attends.

—Please choose an option—Mannford Elementary SchoolMannford High SchoolMannford Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Pawnee Elementary SchoolPawnee High SchoolPawnee Middle SchoolOther

If Other, please type school name below.

Please select a school district in Payne County.

—Please choose an option—Cushing Public SchoolsGlencoe Public SchoolsOak Grove Public SchoolPerkins-Tryon Public SchoolRipley Public SchoolStillwater Public SchoolYale Public Schools

Please select which school this child attends.

—Please choose an option—Cushing High SchoolCushing Lower Elementary SchoolCushing Middle SchoolCushing Upper Elementary SchoolCushing Wilson SchoolOther

Please select which school this child attends.

—Please choose an option—Glencoe Elementary SchoolGlencoe High SchoolOther

Please select which school this child attends.

—Please choose an option—Oak Grove Public SchoolOther

Please select which school this child attends.

—Please choose an option—Perkins-Tryon Elementary SchoolPerkins-Tryon High SchoolPerkins-Tryon Intermediate SchoolPerkins-Tryon Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Ripley Elementary SchoolRipley High SchoolOther

Please select which school this child attends.

—Please choose an option—Highland Park Elementary SchoolLincoln AcademyRichmond Elementary SchoolSangre Ridge Elementary SchoolSkyline Elementary SchoolStillwater High SchoolStillwater Jr. High SchoolStillwater Middle SchoolWestwood Elementary SchoolWill Rogers Elementary SchoolStillwater Pioneer Virtual AcademyOther

Please select which school this child attends.

—Please choose an option—Yale Elementary SchoolYale High SchoolYale Middle SchoolOther

If Other, please type school name below.

Please select a school district in Rogers County.

—Please choose an option—Catoosa Public SchoolsClaremore Public SchoolsCollinsville Public SchoolsFoyil Public SchoolsInola Public SchoolsOologah Public SchoolOwasso Public SchoolSequoyah Public SchoolsVerdigris Public Schools

Please select which school this child attends.

—Please choose an option—Art Goad ElementaryCatoosa High SchoolChelsea High SchoolChelsea Middle SchoolCherokee Elementary SchoolHelen Paul Learning CenterWells Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Catalayah Elementary SchoolClaremont Elementary SchoolClaremore High SchoolJustus-Tiawah North CampusJustus-Tiawah South CampusRoosa Elementary SchoolWestside Elementary SchoolWill Rogers Junior High SchoolOther

Please select which school this child attends.

—Please choose an option—Foyil Elementary SchoolFoyil High SchoolFoyil Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Inola Elementary SchoolInola High SchoolInola Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Oologah-Talala High SchoolOologah-Talala Lower Elementary SchoolOologah-Talala Middle SchoolOologah-Talala Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Pamela Hodson ElementaryStone Canyon ElementaryOther

Please select which school this child attends.

—Please choose an option—Sequoyah Elementary SchoolSequoyah High SchoolSequoyah Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Verdigris Elementary SchoolVerdigris High SchoolVerdigris Junior High SchoolVerdigris Upper Elementary SchoolOther

Please select which school this child attends.

—Please choose an option—Collinsville High SchoolCollinsville Middle SchoolCollinsville Upper Elementary SchoolHerald Lower ElementaryJanice K. Pollard ECCWilson 6th Grade CenterOther

If Other, please type school name below.

Please select a school district in Tulsa County.

—Please choose an option—Berryhill Public SchoolsBixby Public SchoolsBroken Arrow Public SchoolsGlenpool Public SchoolsJenks Public SchoolsOwasso Public SchoolPrivateSand Springs Public SchoolSperry Public SchoolsSummit Christian AcademyTulsa Public SchoolUnion Public Schools

Please select which school this child attends.

—Please choose an option—Berryhill ElementaryBerryhill High SchoolBerryhill Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Bixby 9th Grade CenterBixby Alternative EducationBixby Central ElementaryBixby Central Intermediate SchoolBixby East ElementaryBixby East Intermediate SchoolBixby High SchoolBixby Middle SchoolBixby North ElementaryBixby North Intermediate SchoolBixby West ElementaryBixby West Intermediate SchoolOther

Please select which school this child attends.

—Please choose an option—Arrow Springs Early ChildhoodArrowhead ElementaryAspen Creek Early ChildhoodAspen Creek ElementaryBA Options Academy AlternativeBroken Arrow High SchoolCentennial Middle SchoolChilders Middle SchoolCountry Lane IntermediateCountry Lane PrimaryCreekwood Early ChildhoodCreekwood ElementaryFreshman AcademyHighland Park ElementaryLeisure Park ElementaryLiberty ElementaryLynn Wood ElementaryOak Crest ElementaryOliver Middle SchoolOneta Ridge Middle SchoolPark Lane Early ChildhoodRhoades ElementaryRosewood ElementarySequoyah Middle SchoolSpring Creek ElementaryTimber Ridge ElementaryVandever ElementaryVanguard AcademyVirtual AcademyWolf Creek ElementaryOther

Please select which school this child attends.

—Please choose an option—Glenpool ElementaryGlenpool High SchoolGlenpool IntermediateGlenpool Lower ElementaryGlenpool Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Jenks Alternative CenterJenks East ElementaryJenks East IntermediateJenks Freshman AcademyJenks High SchoolJenks Middle SchoolJenks Northwest ElementaryJenks Southeast ElementaryJenks West ElementaryJenks West IntermediateOther

Please select which school this child attends.

—Please choose an option—Smith Elementary SchoolAtor Elementary SchoolBailey Elementary SchoolBarnes Elementary SchoolHudson ElementaryMills Elementary SchoolMorrow Elementary SchoolOwasso 6th Grade CenterOwasso 7th Grade CenterOwasso 8th Grade CenterOwasso High SchoolOwasso Northeast Elementary SchoolRam Academy - AlternativeOther

Please select which school this child attends.

—Please choose an option—Bishop Kelly High SchoolOther

Please select which school this child attends.

—Please choose an option—Sand Springs 6th Grade CenterSand Springs Angus Vallen ElementarySand Springs Charles Page High SchoolSand Springs Clyde Boyd Middle SchoolSand Springs CPHS Freshman AcademySand Springs Early Childhood Education CenterSand Springs Garfield STEAM AcademySand Springs Limestone Technology AcademySand Springs Northwest Fine Arts AcademySand Springs Page Academy Alternative High SchoolSand Springs Pratt ElementaryOther

Please select which school this child attends.

—Please choose an option—Sperry Elementary SchoolSperry High SchoolSperry Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Summit Christian AcademyOther

Please select which school this child attends.

—Please choose an option—Memorial High SchoolThoreau Demonstration Academy Middle SchoolTulsa - East Central High SchoolWhitman ElementaryBell ElementaryBooker T. Washington High SchoolBurroughs ElementaryCAP Tulsa (Pre-K & Early Childhood)Carnegie ElementaryCarver Middle SchoolCelia Clinton ElementaryCentral High SchoolCentral Middle SchoolClinton West ElementaryCollege Bound Academy ElementaryCollegiate Hall Elementary & MiddleCooper ElementaryCornerstone (Pre-K & Early Childhood)Council Oak ElementaryCrosstown (Pre-K & Early Childhood)Daniel Webster High SchoolDaniel Webster Middle SchoolDisney ElementaryDolores Huerta ElementaryEast Central Junior High SchoolEdison Prepatory High SchoolEdison Prepatory Middle SchoolEducare (Pre-K & Early Childhood)Eisenhower International Elementary MagnetEliot ElementaryEmerson ElementaryEugene Field ElementaryFelicitas Mendez International ElementaryGreenwood Leadership Academy ElementaryGrissom ElementaryHale High SchoolHamilton ElementaryHawthorne ElementaryHenry Zarrow International Elementary MagnetHoover ElementaryJohn Hope Franklin ElementaryKendall-Whittier ElementaryKerr Elementary SchoolKey ElementaryKIPP Tulsa University Prep High SchoolLanier ElementaryLewis and Clark ElementaryLindbergh ElementaryMacArthur ElementaryMarshall ElementaryMayo Demonstration Elementary (Magnet)McClure ElementaryMcKinely ElementaryMcLain High SchoolMitchell ElementaryMonroe Demonstration Academy Middle SchoolNorth Star Academy High - AlternativeOwen ElementaryPatrick Henry ElementaryPeary ElementaryPhoenix Rising High School - AlternativeRobertson ElementarySalk ElementarySequoyah ElementarySkelly ElementarySpringdale ElementaryStreet School High School - AlternativeTulsa Anderson ElementaryTulsa Honor Academy High SchoolTulsa Honor Academy Middle SchoolTulsa Legacy Charter Primary Academy (Elem)Tulsa Legacy Charter Upper Academy (Middle)Tulsa MET High School - AlternativeTulsa MET Middle - AlternativeTulsa School of Arts and Sciences High SchoolTulsa Tech Career AcademyTulsa Virtual Academy ElementaryTulsa Virtual Academy HighTulsa Virtual Academy MiddleUnity Learning Academy ElementaryWayman Tisdale Fine Arts Academy ElementaryWill Rogers College High SchoolWill Rogers College Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Union 8th Grade Center6th & 7th Grade CenterBoevers ElementaryBroken Arrow Anderson ElementaryCedar Ridge ElementaryDarnaby ElementaryEllen Ochoa ElementaryGrove ElementaryJarman ElementaryJefferson ElementaryMcAuliffe ElementaryMoore ElementaryPeters ElementaryRosa Parks Early ChildhoodRosa Parks ElementaryRoy Clark ElementaryUHS Freshman AcademyUnion Alternative SchoolUnion High SchoolOther

If Other, please type school name below.

Please select a school district in Washington County.

—Please choose an option—Bartlesville Public SchoolsCaney Valley Public SchoolsCopan Public SchoolsDewey Public Schools

Please select which school this child attends.

—Please choose an option—Bartlesville High SchoolMadison Middle SchoolRanch Heights Elementary SchoolRichard Kane Elementary SchoolWayside Elementary SchoolWoodrow Wilson ElementaryJane Phillips Elementary SchoolHoover Elementary SchoolCentral Middle SchoolOther

Please select which school this child attends.

—Please choose an option—Caney Valley Elementary School - OchelataCaney Valley High SchoolOther

Please select which school this child attends.

—Please choose an option—Copan High SchoolOther

Please select which school this child attends.

—Please choose an option—Dewey Elementary SchoolDewey High SchoolDewey Middle SchoolOther

If Other, please type school name below.

Child's grade

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

Medicaid (SoonerCare) Member Number

Medicare Member Number

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

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.

Name*

Relationship to individual being referred*

Phone*

Email

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