GETTING STARTED

The first step is the hardest. We’re here to help you through your journey.

This form must be completed by the person seeking treatment. These questions are required by the Oklahoma Department of Mental Health.

Walk In Screenings are available at our Norman Office: Monday through Thursday, 9:30 am to 4:30 pm, and on Fridays from 8 am to 11 am. We can also provide initial screenings via telephone or telehealth.

Give us a call at 405-321-0022, stop by our office, or fill out the online form to get started.During your first visit, you will be able to meet with a clinician. We will discuss your needs and how The Virtue Center can assist you. Immediate treatment options are available based on initial screening. All services are confidential.

Your initial screening is provided at no cost. At your assessment, you will work with a therapist to build an individualized treatment plan that best meets your vision of recovery. The treatment plan will include a combination of services to help you achieve your recovery goals.

Fees for services are determined based on a sliding scale with options for Medicaid and other financial assistance if qualified. For clients with private insurance, payment is due at the time of service, but we can assist you in completing claims. We have therapists in-network with Blue Cross Blue Shield.

Name

First NameLast Name
Maiden name
Date of birth

MonthDayYear
Date
Phone #
Can we leave a voicemail at this phone number?
If yes, what can we say?
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race and Ethnic Origin - Choose one (required by ODMHSAS)

Pacific Islander or Native HawiianBlack/ African AmericanAsianWhiteNative American
Hispanic/Latino?
Preferred Pronouns
Sex
SSN
How did you hear about us? Be specific.
Please explain why you are here today:
Financial Information (This helps us determine if you will pay using our sliding scale or if you qualify for state benefits Do you have Soonercare / Medicaid?) *If your financial information ever changes, please alert the front desk.
Annual household income
How many people in your household are you financially responsible for? (Include yourself)
List any special needs or accommodations:
Are you currently pregnant?
Do you use tobacco products?
If yes, please complete the following: Would you like assistance with quitting nicotine use?
If yes, please sign below. "I authorize the Oklahoma Tobacco Helpline to contact me."

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Emergency contact information (name, relation, phone number, address)
Lastly, do you have any special accommodations we should know about? You may also add any other information you'd like us to be aware of.
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