Get Started with Services
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  • 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.
  • Format: (000) 000-0000.
  • May we leave a message at the preferred number?*
  • Race (select all that apply) of Client*
  • Ethnicity of Client*
  • Pronouns of Client
  • If Client is an Adult, are you an Armed Forces Veteran/Active Duty? If Client is a child, is an immediate caregiver an Armed Forces Veteran/Active Duty?*
  • Format: (000) 000-0000.
  • Is the client 5 years of age or younger?*
  • Is Client between the ages 6 to 18?*

  • Authority to Consent for Services for Minors

    This consent form is subject to review and approval to ensure it meets all legal and ethical standards for mental health services and is in the best interest of your child. We will notify you once the review process is complete.

  • I, *   * am     *   of*   *   and have legal authority to consent for the aforementioned child to be seen at Sunbeam Family Services, Inc. for outpatient counseling.

  • My Legal guardianship of the minor is:*
  • Please choose the following regarding your relationship with the child's other biological parent.*
  • Please check one of the following:*
  • To show proof of guardianship and authority to consent to mental health services for a minor, you can provide the following court-approved documents. Please Note: These documents must be approved by the court to ensure they are legally valid.
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  • Is there a custody agreement in place?*
  • Is there currently DHS Custody?*
  • Format: (000) 000-0000.
  • What type of mental health service are you looking for?*
  • How can we help? (Select all that apply)*

  • 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?)*
  • Experienced hallucinations (heard or seen things others don't hear or see)?*
  • Experienced thoughts of harming yourself?*
  • Attempted suicide?*
  • Been prescribed medication for any psychological or emotional problem?*

  • Domestic Violence

  • Have you ever been afraid of your partner and/or a family member?*
  • Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone?*
  • If you answered yes to either of the above questions, is the person who hurt or threatened you still a part of your life?*
  • Have you ever used gestures, threats, and/or thrown or broken objects as a means to intimidate your partner or a family member?*
  • Have you ever pushed, restrained, hit, slapped, or used any other physical means to harm your partner or a family member?*

  • Trauma

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

  • Substance Use

    During the past year, have you:
  • Drank alcohol and/or used drugs more than you intended?*
  • Tried to stop drinking alcohol and/or using other drugs, but couldn't?*
  • Experienced problems caused by drinking alcohol and/or using drugs, and you kept using?*
  • Drank alcohol and/or used other drugs to alter the way you feel?*
  • Been preoccupied with drinking alcohol and/or using other drugs?*
  • Needed to drink more alcohol and/or use more drugs to get the same effect you used to get with less?*

  • Pediatric Symptom Checklist (PSC)

    Please indicate that which best describes your child:
  • Complains of aches and pains.*
  • Spends more time alone.*
  • Tires easily, has little energy.*
  • Fidgety, unable to sit still.*
  • Has trouble with teacher.*
  • Less interested in school.*
  • Acts as if driven by a motor.*
  • Daydreams too much.*
  • Distracted easily.*
  • Is afraid of new situations.*
  • Feels sad, unhappy.*
  • Is irritable, angry.*
  • Feels hopeless.*
  • Has trouble concentrating.*
  • Less interested in friends.*
  • Fights with other children.*
  • Absent from school.*
  • School grades dropping.*
  • Is down on themselves.*
  • Visits the doctor with doctor finding nothing wrong.*
  • Has trouble sleeping.*
  • Worries a lot.*
  • Wants to be with you more than before.*
  • Feels they are bad.*
  • Takes unnecessary risks.*
  • Gets hurt frequently.*
  • Seems to be having less fun.*
  • Acts younger than children their age.*
  • Does not listen to rules.*
  • Does not show feelings.*
  • Does not understand other people's feelings.*
  • Teases others.*
  • Blames others for their troubles.*
  • Takes things that do not belong to them.*
  • Refuses to share.*

  • 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
  • Easily upset by Noise, Touch, Smells, Tastes, Open or Busy Spaces
  • Serious Developmental Delays
  • Emotional Difficulties
  • Challenging Behaviors
  • Relationship Difficulties
  • Other common responses to a scary or painful event

  • 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?
  • 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?
  • 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?
  • 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?
  • 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?
  • Were your parents ever separated or divorced?
  • 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?
  • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
  • Was a household member depressed or mentally ill or did a household member attempt suicide?
  • Did a household member go to prison?
  • Check all that apply
  • I am currently involved in the following services at Sunbeam
  • How did you hear about us?*
  • Availability for Appointments (select all that apply)*
  • Are you apart of Medicaid's new SoonerSelect coverage? If so which one.
  • Which of the following options best suits you? (Please note that these options are based on administrative approval).

  • 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

  • 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.

  • Employment Status:
  • Employment Role:
  • Years Employed:
  • Age:
  • How would you describe your current functioning at work/school:
  • How would you describe your current functioning at home and with family:
  • How would you describe your current functioning with friends and family:

  • 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* 

  • Date of Birth of Insured (if different from self)*
     - -
  • Account Responsible Date of Birth
     - -
  • Format: (000) 000-0000.
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  • 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.

  • 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.

  • 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.

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