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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Sooner SUCCESS Referral

Please complete the form below.

Who is making the referral?

* must provide value

Provider

Caregiver

OKDHS

JumpStart Clinic

TEFRA Staff Use Only

Sooner Success Staff Use Only

Other

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What is your clinic/program?

Provider Information:

First Name

Last Name

Phone Number?

Referring OKDHS Worker Contact Information:

First Name

Last Name

Phone Number?

Are you interested in the following services/resources?

[mark all that apply]

Respite

Supplemental Formula

Healthcare Transition to Adulthood

Autism Evaluation

Developmental Evaluation

Behavioral Therapy

Individual Counseling

On The Road

Parent(s) need assistance with CHILD'S disability

Parent needs assistance with their OWN disability

Other

Please describe any other services/resources we can provide.

* must provide value

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Who in the family has a diagnosed or suspected disability?

One of the Parents/Caregivers

Both Parents/Caregivers

One of the children (below age 21)

More than one of the children (below age 21)

A non-parent adult self-advocate (over the age of 21)

What is parent or caregiver's disability, check all that apply

Intellectual/Cognitive

Learning

Physical

Sensory

Mental/Psychiatric

Parent/Family Caregiver/Adult Self Advocate with Disabilities Information:

First Name

Last Name

Preferred Phone Number?

Alternate Phone Number

Caregiver's Email Address?

https://redcap.link/SSFeedback

If yes, check all that apply:

Intellectual/cognitive

Learning

Physical

Sensory

Mental/psychiatric

Does family require Spanish translation?

Yes

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Is your primary client:

The parent with a disability (be sure parent disability is checked and submit the parent's information below)

A child or adult self advocate with a disability who is not a parent (submit the child or self-advocate's information)

A family that includes both a child and a parent with a disability (be sure parent disability is checked and submit the child's information below)

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Client First Name

Client Last Name

Client's Date of Birth
?OR

Please enter approximate age:

Client's Gender:

Male

Female

Other

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If Other, what is child's current gender identity? (Check ALL that apply)

If Other, what is child's preferred pronoun (Check ALL that apply)

Add another client?

Yes

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Client First Name

Client Last Name

Client's Date of Birth
?OR

Please enter approximate age:

Client's Gender:

Male

Female

Other

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If Other, what is child's current gender identity? (Check ALL that apply)

If Other, what is child's preferred pronoun (Check ALL that apply)

Does either parent/caregiver have a disability?

Yes

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Client's Address

Clients Street Address?

Clients City

Client County

Client State

Client Zip Code

Client's City

Client Diagnosis

Client Other Diagnosis

Other Diagnosis

Second Other Diagnosis

Is the child in DHS custody?

Yes

Unknown

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Please select client's insurance

Please state client's other insurance, if any

Please provide any information that will help us better support the family.

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Please attach any reference document you have here

Upload file

For a confirmation email and copy of your referral, please provide an email address here:

Today's Date

M-D-Y

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