Referral Database Businesses or Practices

The Oklahoma Mental Health Network (OMHN) is a comprehensive network of all mental health services and resources across the state of Oklahoma including adjunctive situations such as domestic violence, developmental disabilities, and family needs. This form asks basic questions about your services relevant to pediatric mental health. The intended use of this information is to provide a referral network for the Oklahoma Child and Adolescent Psychiatry and Mental Health Access Program (OKCAPMAP) to assist pediatric serving (0-21 years old) primary care providers across the state with successful referrals to therapeutic services and supports. This survey is for practices and businesses. Please only complete this survey for a business or practice.

Thank you for taking the time to complete this survey and for helping bridge the gap in pediatric mental health care in Oklahoma.

Mental Health and Related Services

Thank you for sharing information about your practice or business services and resources that are relevant to the health and wellness of families, children and adolescents (ages 0-21).

Name of business(Required)

Business phone number (e.g., 918-710-3600)(Required)

Primary physical address (e.g., 5310 E 31st St.)(Required)

City for primary physical address (e.g., Tulsa)(Required)

State for primary physical address(Required)

Other state for primary physical address

Zip code for primary physical address (e.g., 74135)(Required)

County for primary physical address(Required)

Business days(Required)

Business hours (e.g., Monday 8AM-5PM, Tuesday 10AM-2PM, Friday 4PM-8PM or M-F 8AM-5PM)(Required)

Notes about business. Please share any additional information or upcoming changes.

Name of contact person(Required)

Contact credentials (any credentials that apply to you)(Required)

Other contact credentials

Contact role(Required)

Other contact role

Enter your role.

Contact email(Required)

Notes about contact person. Please share any additional information or upcoming changes.

Age ranges served(Required)

Types of services(Required)

Specific outpatient services your facility provides (Please include contracted or partner services in the "other" section.)(Required)

Other specific outpatient services

Specific inpatient services your facility provides (Please include contracted or partner services in the "other" section.)(Required)

Other specific inpatient services

Specific residential services your facility provides (Please include contracted or partner services in the "other" section.)(Required)

Other specific residential services

Specific crisis response services your facility provides (Please include contracted or partner services in the "other" section.)(Required)

Other specific crisis response services

Do you offer tele-health or tele-therapy?

Yes

No or N/A

County/counties where services are provided (Select any counties you provide services in. If you serve the whole state, only select "Statewide/All counties". Do not include telehealth.)(Required)

Insurances accepted(Required)

Other insurances accepted(Required)

Sliding scale/adjusted fee for un/under insured(Required)

Yes

No or N/A

Special populations served(Required)

Other special populations served (e.g., medically complex, veteran/service member).

Marginalized populations specifically served(Required)

Other marginalized populations served (e.g., the specific tribal affiliation – Cherokee, english as a second language)

Tribal affiliation members served(Required)

Other tribal affiliation members served (e.g., Osage Nation, Quapaw Tribe)

Ancillary services provided(Required)

Other ancillary services

Additional services provided(Required)

Other additional services

Bilingual providers(Required)

Other bilingual providers

Enter any languages in which services are offered, otherwise not listed above (e.g., Hmong).

Language translation service(Required)

Other language translation (e.g., Arabic)(Required)

Notes about services. Please share any additional information or upcoming changes.

Website(s)