Get Started with Services

Get Started with Services

Mental Health Client Initial Referral and Paperwork
Electronic Communication

Please check the box below to consent for Sunbeam to follow up with regarding this referral and scheduling via email. Please allow up to 20 minutes to complete this form.
I understand that by completing this form I am consenting for Sunbeam to communicate with me via the email listed below regarding my referral and possible future scheduling of services.*

I consent
Name of Client*

First NameLast Name
Legal Name of Client (if different from above)

First NameLast Name
Name of Person Completing Form*

First NameLast Name
Relationship to Client*
Phone Number*
Please enter a valid phone number.
May we leave a message at the preferred number?*

YesNo
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of Client*
Sex (For Billing Purposes Only)of Client*
Race (select all that apply) of Client*

American Indian/AlaskanAsianBlack/African AmericanHawaiian/Pacific IslanderHispanic/LatinoWhite/Caucasian
Ethnicity of Client*

Hispanic/LatinoNot Hispanic/Latino
Primary Language of Client*
Primary Language of Guardian*
Marital Status of Client*
Gender of Client
Pronouns of Client

He/HimShe/HerThey/ThemOther
Emergency Contact*

First NameLast Name
Relationship to Client*
Phone Number of Emergency Contact*
Please enter a valid phone number.
Is the client under 5 years of age?*

YesNo
Is Client between the ages 6 to 18?*

YesNo
Parent or Guardian Name*

First NameLast Name
Is there a custody agreement in place?*

YesNo
Is there currently DHS Custody?*

YesNo
If Yes, DHS Worker Name*

First NameLast Name
DHS Worker Email*
example@example.com
DHS Work Phone Number*
Please enter a valid phone number.
What type of mental health service are you looking for?*

Individual (Just me/Just client)CouplesFamily
How can we help? (Select all that apply)*

AnxietyAngerDepressionFamily ConflictGrief/LossTraumaSubstance useVictim of CrimeWork or School IssueOther
Tell us what you're looking for in your counseling experience and specificallyin the therapist who works with you.
Tell us what you're looking
Tell us what you're looking for in your counseling experience and specifically in the therapist who works with you.
Mental Health

Within the last 90 days (3 months) have you had a significant period in which you have:
Experienced serious depression (felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficulty going about your daily activities?)*

YesNo
Experienced hallucinations (heard or seen things others don't hear or see)?*

YesNo
Experienced thoughts of harming yourself?*

YesNo
Attempted suicide?*

YesNo
Been prescribed medication for any psychological or emotional problem?*

YesNo
Domestic Violence
Have you ever been afraid of your partner and/or a family member?*

YesNo
Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone?*

YesNo
If you answered yes to either of the above questions, is the person who hurt or threatened you still a part of your life?*

YesNo
Have you ever used gestures, threats, and/or thrown or broken objects as a means to intimidate your partner or a family member?*

YesNo
Have you ever pushed, restrained, hit, slapped, or used any other physical means to harm your partner or a family member?*

YesNo
Trauma
Have you experienced a traumatic event and since had repeated nightmares/dreams and/or anxiety which interferes with you leading a normal life?*

YesNo
Substance Use

During the past year, have you:
Drank alcohol and/or used drugs more than you intended?*

YesNo
Tried to stop drinking alcohol and/or using other drugs, but couldn't?*

YesNo
Experienced problems caused by drinking alcohol and/or using drugs, and you kept using?*

YesNo
Drank alcohol and/or used other drugs to alter the way you feel?*

YesNo
Been preoccupied with drinking alcohol and/or using other drugs?*

YesNo
Needed to drink more alcohol and/or use more drugs to get the same effect you used to get with less?*

YesNo
Pediatric Symptom Checklist (PSC)

Please indicate that which best describes your child:
Complains of aches and pains.*

NeverSometimesOften
Spends more time alone.*

NeverSometimesOften
Tires easily, has little energy.*

NeverSometimesOften
Fidgety, unable to sit still.*

NeverSometimesOften
Has trouble with teacher.*

NeverSometimesOften
Less interested in school.*

NeverSometimesOften
Acts as if driven by a motor.*

NeverSometimesOften
Daydreams too much.*

NeverSometimesOften
Distracted easily.*

NeverSometimesOften
Is afraid of new situations.*

NeverSometimesOften
Feels sad, unhappy.*

NeverSometimesOften
Is irritable, angry.*

NeverSometimesOften
Feels hopeless.*

NeverSometimesOften
Has trouble concentrating.*

NeverSometimesOften
Less interested in friends.*

NeverSometimesOften
Fights with other children.*

NeverSometimesOften
Absent from school.*

NeverSometimesOften
School grades dropping.*

NeverSometimesOften
Is down on themselves.*

NeverSometimesOften
Visits the doctor with doctor finding nothing wrong.*

NeverSometimesOften
Has trouble sleeping.*

NeverSometimesOften
Worries a lot.*

NeverSometimesOften
Wants to be with you more than before.*

NeverSometimesOften
Feels they are bad.*

NeverSometimesOften
Takes unnecessary risks.*

NeverSometimesOften
Gets hurt frequently.*

NeverSometimesOften
Seems to be having less fun.*

NeverSometimesOften
Acts younger than children their age.*

NeverSometimesOften
Does not listen to rules.*

NeverSometimesOften
Does not show feelings.*

NeverSometimesOften
Does not understand other people's feelings.*

NeverSometimesOften
Teases others.*

NeverSometimesOften
Blames others for their troubles.*

NeverSometimesOften
Takes things that do not belong to them.*

NeverSometimesOften
Refuses to share.*

NeverSometimesOften
Child-Parent Psychotherapy (CPP) Screener

When problems last more than one month, happen more often, or are stronger than would be expected given the child's age.
Continued problems with Body Functions

SleepingFeeding or EatingPotty training or going to the bathroom
Easily upset by Noise, Touch, Smells, Tastes, Open or Busy Spaces

YesNo
Serious Developmental Delays

SpeechMotorSocial skillsExploration and Play
Frequent Health Problems (e.g. illness, aches, asthma)
Emotional Difficulties

Often angry, irritableTantrums (Stronger and longer than others their age)Sad, cried a lot, hard to comfortOverly worried or scaredSerious problems separating, overly clingyOverly quiet, shy, shut-down
Challenging Behaviors

Aggressive, defiantOveractiveProblems paying attentionReckless, frequent accidents (gets hurt a lot)
Relationship Difficulties

More distant or less connected to people than usualDoesn't play with other children, wants to be aloneOverly friendly with strangers.
Other common responses to a scary or painful event

Bad dreamsEasily scaredTalking or playing a lot about what happenedAvoiding talking about what happened or avoiding places, people. or things connected to the eventSudden change in mood or behaviors when reminded of what happenedSpacing out frequently or when reminded or what happenedWorrying that bad things will happen againLooking out for danger, jumpyEngaging in sexual behaviors that are not age appropriate
Adverse Childhood Experience (ACE) Questionnaire

When growing up, during the first 18 years of life:
Did a parent or other adult in the household often swear at you, insult you, put you down, humiliate you or act in a way that made you afraid that you might be physically hurt?

YesNo
Did a parent or other adult in the household often push, grab, slap, or throw something at you; or ever hit you so hard that you had marks or were injured?

YesNo
Did an adult or person at least five years older than you ever touch or fondle you or have you touch their body in a sexual way; or try to actually have oral, anal, or vaginal sex with you?

YesNo
Did you often feel that no one in your family loved you or thought you were important or special; or your family didn't look out for each other, feel close to each other, or support each other?

YesNo
Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you; or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

YesNo
Were your parents ever separated or divorced?

YesNo
Was your mother or step mother often pushed, grabbed, slapped, or had something thrown at her; or sometimes or often kicked, bitten, hit with a fist, or with something hard; or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

YesNo
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

YesNo
Was a household member depressed or mentally ill or did a household member attempt suicide?

YesNo
Did a household member go to prison?

YesNo
Please add up all of your "Yes" responses and put the total here:
Check all that apply

I (or my child) received services in the past at SunbeamI was referred by another agencyI have an open case with DHS
I am currently involved in the following services at Sunbeam.
I am currently involved in the following services at Sunbeam

Parent EducationGrandparents Raising GrandchildrenHome VisitationFoster CareCaregiver Support GroupEducare Early Education CenterEdwards Early Education CenterHarbison Early Education CenterMetro Tech Early Education CenterMillwood Early Education CenterPierce Early Education CenterEmerson Little WondersGatewood Early Learning CenterHope at ReMergeLinwood Early Learning CenterLittle HeartsPositive TomorrowsSouthwest Child DevelopmentStar Spencer High SchoolTony Reyes Bilingual CDCUS Grant Little GeneralsWovenLife
How did you hear about us?*

Boys and Girls ClubBench AdBillboardBus AdFriend/Family MemberInternetNewspaperOKCPSPalomarRadioSocial MediaSunbeam Early Childhood ServicesSunbeam Foster CareSunbeam Parent EducationSunbeam Grandparents Raising GrandchildrenTVWork
Availability for Appointments (select all that apply)*

MondayTuesdayWednesdayThursdayFridayMornings (8am-Noon)Afternoons (Noon-4pm)Evenings (4pm-8pm)
Annual Income*
Number of Individuals Living in Household*
How will you be paying for services?*
Are you apart of Medicaid's new SoonerSelect coverage? If so which one.

Aetna Better HealthHumana Healthy HorizonsOklahoma Complete Health
EAP Eligibility, Services and Cost
Your Employee Assistance Program (EAP) is provided through Sunbeam Family Services and offers confidential service to all eligible employees and their covered family members to help address issues impacting quality of life, emotional well-being and productivity at work. Services are provided by the EAP at no cost to you, and can include:
- Assessment/Consultation
- Brief counseling
- Referral to service providers outside EAP
- Referral to community resources outside EAP
You are responsible for any costs associated with services beyond the EAP benefit. As these expenses may be covered in part or full under your medical plan, you should contact your plan prior the onset of this care for specific information on coverage and benefit authorization.

Confidentiality
EAP services are strictly confidential. No information concerning your use of EAP will be disclosed to any party outside the EAP except in the following circumstances:
- You consent in writing
- You request that EAP speak with your health plan provider to assist in benefits verification for treatment recommended beyond EAP
- The law requires disclosure to appropriate parties.
Participation

Voluntary Participation: Use of the EAP is voluntary and your employment will in no way be affected by your use of this program. However, participation in the EAP does not prevent your employer from taking actions regarding unacceptable work performance or behavior. If your management, due to a work performance problem, referred you to EAP, the EAP will not advise your management of your participation without your written consent on a separate Disclosure of Confidential Information form.Mandatory Participation: Your company as a condition for your continued employment has required your use of EAP, permission for its disclosure of specified information, and compliance with recommendations made. Failure to sign Disclosure of Confidential Information form could constitute a failure to comply with conditions of your employment under your company’s policies.
Appointment Cancellation

Should you need to cancel an EAP appointment you must notify your EAP therapist at least 24 hours prior to the scheduled appointment. Failure to do so will be considered as a late cancel or no show and will be counted as one of your allotted sessions. EAP reserves the right to terminate services when appointments are cancelled without appropriate notification.
I have read and understood what is being said.

Yes
Employment Status:

Full timePart timeNot applicable
Employment Role:

ManagementNon-managementOtherNot applicable
If other, please explain.
Years Employed:

0-12-45-910-1516 plusNot applicable
Age:

0-910-1920-2930-3940-4950-6565+
How would you describe your current functioning at work/school:

ExcellentVery goodGoodFairPoor
How would you describe your current functioning at home and with family:

ExcellentVery goodGoodFairPoor
How would you describe your current functioning with friends and family:

ExcellentVery goodGoodFairPoor
My problems are impacting my productivity at work/school:

1

2

3

4

5

1 is No impact at all, 5 is Highly impacted
My problems are impacting my attendance at work/school:

1

2

3

4

5

1 is No impact at all, 5 is Highly impacted
My problems are impacting my work/school relationship:

1

2

3

4

5

1 is No impact at all, 5 is Highly impacted
Primary insurance
Secondary insurance
Which of the following options best suits you? (Please note that these options are based on administrative approval).

Self PayMaster's level therapist: SUBJECT TO AVAILABILITY. This is at no charge to you. Our master's level therapists are in the internship phase of their training and are in the process of gaining clinical experience under the supervision of a highly qualified licensed therapist as well as the Clinical Director of Sunbeam.
2024 Sunbeam Mental Health Fee Schedule**

90791 Psychiatric Diagnostic Evaluation ……$215.00       
90832 Psychotherapy – 30 minutes …………$ 95.00
90834 Psychotherapy – 45 minutes…………$125.00
90837 Psychotherapy – 60 minutes .....$180.00

90846 Family psychotherapy without client present.....$125.00
90847 Family psychotherapy with client present........$125.00
90853 Group Psychotherapy …………$35.00

90839 Crisis intervention (up to 90 minutes)....$250.00

90840 Extended crisis intervention (90+ minutes)....$125.00
H0031 Mental Health Assessment ………. $175.00
H0004 Psychotherapy – per unit ……… $35.00
NO SHOW/Late Cancelation ……………$50.00

Cash/Self Pay Discount: Our standard cash pay rate is $100 per hour* if paid at the time of service.
*Hourly rates will apply with billing increments rounded to the nearest 15 minutes for any time exceeding one hour. Please note that assessments are typically 1.5 hours*
Insurance Company*
Insurance Member ID Number*
Insurance Group Number
Name of Insured (if different from self)

First NameLast Name
Date of Birth of Insured (if different from self)

MonthDayYear
Date
Social Security Number of Insured (if different from self)
If using an EAP or Mental Health Services benefit, what employer provides your benefit? If you do not see your employer below, please contact your HR to find out who your EAP services are through.*
Account Responsible Name (if self, leave blank; if parent/legal guardian, please fill out below)

First NameLast Name
Account Responsible Date of Birth

MonthDayYear
Date
Account Responsible Phone
Please enter a valid phone number.
Account Responsible Email
example@example.com
Account Responsible Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a Copy of the Insurance Card

Cancelof
Email Communication Terms and Conditions:

Sunbeam offers clients the opportunity to communicate by email with providers and Sunbeam staff regarding their (or child’s) services. Transmitting this information poses several risks and clients should not agree to communicate via email without understanding and accepting these risks.
The risks include, but are not limited to, the following:
• The privacy and security of email communication cannot be guaranteed.
• Email senders can misaddress, resulting in it being sent to many unintended recipients.
• Employers/online services may have a legal right to inspect and keep emails that pass through their system.
• Even after deletion of the email, back‐up copies may exist on a computer.
• Email is easier to falsify than signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email.
• Emails can introduce viruses, generally damage, or disrupt the computer.
• Email communications may disclosed upon valid court orders.
Conditions of Using Email
Sunbeam will use reasonable means to protect the security and confidentiality of email information sent and received, however, Sunbeam cannot guarantee the security of email communication. Thus, clients must consent to the use of email for client information, billing, and communication. Consent to use email includes agreement with the following conditions:
• Emails to or from the client concerning treatment may be printed in full and made part of the client’s medical record. As part of the medical record, authorized individuals will have access the medical record/email (e.g. billing staff).
• Sunbeam may forward emails internally to those involved, as necessary, for healthcare operations and other handling. Our therapists will not forward emails to independent third parties without the client’s prior written consent, except as authorized or required by law.
• Although Sunbeam will endeavor to read and respond promptly to all emails from clients, it is not guarantee that any particular email will be read and responded to within any particular period of time.
• Clients should not use email for emergencies or other time‐ sensitive matters.
• If a client’s email invites a response from the therapist and a response is not received within a reasonable time period, it is the client’s responsibility to follow up.
• Changes to appointment times should be communicated by phone to the number provided to clients.
• Sunbeam is not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider.
Client acknowledgment and agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between the Sunbeam and me, and consent to the conditions outlined herein, as well as any other instructions that Sunbeam may impose to communicate with clients by email. I acknowledge Sunbeam’s right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered at this time.
I consent to the Email Communication outlined above.

I consent
By submitting this document:

I understand that completion of this document is for the purpose of determining client suitability for services and does not guarantee services provided by Sunbeam and that referral resources will be provided for those who do not qualify.
Signature*

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If you have any questions or concerns, please contact us at (405)-528-7721 or mentalhealth@sunbeamfamilyservices.org Thank you for choosing Sunbeam Family Services.
Note: The information provided in this application will be treated with confidentiality and used solely for the purpose of determining eligibility for the sliding fee scale. The actual sliding fee scale percentages and payment amounts will be communicated to the applicant upon review of the application and supporting documentation.
Should be Empty:

Get Started with Services

Electronic Communication

Mental Health

Domestic Violence

Trauma

Substance Use

Pediatric Symptom Checklist (PSC)

Child-Parent Psychotherapy (CPP) Screener

Adverse Childhood Experience (ACE) Questionnaire

By submitting this document: