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405-841-4800
501 N. Walker, Suite 140 Oklahoma City, OK 73102
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Who We Are
Staff and Board of Directors
Careers
History
News & Transparency
Calm Waters Book Club
Our Services
Counseling and Consultation
Grief Support Groups
Divorce Support Groups
Student Support Groups
Grief Training
Co-Parenting Seminars (Court Approved)
Partnership Programs
Incarcerated Oklahomans Grief Support
Grief Support and Education for Medical Professionals
Community Crisis Services
Camp Courage
Webinar Series
Resources
Volunteer
Join the Volunteer Team
Volunteer Training
Internships
Events
Under the Big Top
Ripples of Hope
Ways to Give
Charlotte Lankard Giving Society
Sailing Club
Menu
Who We Are
Staff and Board of Directors
Careers
History
News & Transparency
Calm Waters Book Club
Our Services
Counseling and Consultation
Grief Support Groups
Divorce Support Groups
Student Support Groups
Grief Training
Co-Parenting Seminars (Court Approved)
Partnership Programs
Incarcerated Oklahomans Grief Support
Grief Support and Education for Medical Professionals
Community Crisis Services
Camp Courage
Webinar Series
Resources
Volunteer
Join the Volunteer Team
Volunteer Training
Internships
Events
Under the Big Top
Ripples of Hope
Ways to Give
Charlotte Lankard Giving Society
Sailing Club
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CONTACT
Service Request Form
Your First and Last Name
*
Are you seeking services for yourself or a minor child?
*
Self
Minor Child
How did you hear about Calm Waters?
Word of Mouth
Social Media
Website
Calm Waters email newsletter
Newspaper
Counselor referral
Client Information
Please complete the following section with information about the person for whom services are being sought.
First and Last Name
*
Date of Birth
*
Legal Parent or Guardian Name (if client is under 18)
Phone number
*
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
*NOTE: In order to access services, you must be a resident of Oklahoma.
Services Requested
Please indicate which of the following grief/loss experiences has led you to seek out services.
*
Death
Anticipated Death
Pregnancy Loss
Infertility
*NOTE: Calm Waters is only able to serve those who are experiencing grief/loss related to one of the above.
What type of service are you looking for?
*
Individual Counseling
Couple/Marriage Counseling
Family Counseling
Consultation (1-3 sessions of guidance/psychoeducation)
*Note: Individual counseling services are available for ages 6+. Children ages 5 years and under will be served through family sessions involving at least one parent/caregiver.
Please share with us a little about what is going on and how we can help?
*
Payment
Please indicate your understanding that Calm Waters may not be able to bill your insurance and that a sliding fee scale may be offerred.
*
I understand.
Client's insurance provider (if applicable).
Client's Member ID for above insurance (if applicable).
Your household's estimated annual income (including child support, SSI/SSDI, etc.)
*
The number of people residing in your household.
*
Coupon
Initial Service Consultation
Price:
Calm Waters staff will contact you after this form and payment is submitted for scheduling.
Total
$0.00
Credit Card
Card Details
Cardholder Name
