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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?*

    Please select a school district in Craig County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Delaware County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Kay County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Mayes County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Noble County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Nowata County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Osage County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Ottawa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Pawnee County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Payne County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Rogers County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Tulsa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Washington County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    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

    Email

    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*

    Email

    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*

    Email

    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*

    Email

    Name of legal guardian*

    Relationships to individual

    Phone*

    Email

    Details of person submitting form

    Name*

    Relationships to individual*

    Phone*

    Email

    Details of legal guardian

    Name*

    Relationships to individual

    Phone*

    Email

    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?*

    Please select a school district in Craig County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Delaware County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Kay County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Mayes County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Noble County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Nowata County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Osage County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Ottawa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Pawnee County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Payne County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Rogers County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Tulsa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Washington County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    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

    Email

    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*

    Email

    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*

    Email

    Details of the person making the referral

    Name*

    Relationship to individual being referred*

    Phone*

    Email

    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?*

    Please select a school district in Craig County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Delaware County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Kay County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Mayes County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Noble County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Nowata County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Osage County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Ottawa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Pawnee County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Payne County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Rogers County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Tulsa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Washington County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    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

    Email

    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*

    Email

    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*

    Email

    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*

    Please select a school district in Craig County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Delaware County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Kay County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Mayes County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Noble County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Nowata County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Osage County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Ottawa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Pawnee County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Payne County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Rogers County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Tulsa County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    If Other, please type school name below.

    Please select a school district in Washington County.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    Please select which school this child attends.

    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*

    Email

    Details of the person making the referral

    Name*

    Relationship to individual being referred*

    Phone*

    Email

    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.