Counselor Reimbursement Form Consent(Required) I agree to the following.I understand Oklahoma Baptists’ will not pay more than $80.00 per session effective January 1, 2023. I also agree to request a $10.00 co-pay per session from this client in which I am requesting services through our office’s partnership with Oklahoma Baptists.Counselor's Name(Required) First Last Clinic Name(Required) Phone(Required)Case Number(Required) Email(Required) Clinic Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who are you seeing?(Required) Staff Staff's Immediate Family Presenting Problem:(Required)Treatment Goals:(Required)Request for additional sessions:(Briefly describe the rationale for the additional sessions and attached treatment plan)For any questions, please call our Church Relations office at (405) 942-3800 ext. 4552
