Client Portal - The Center for Christian Counseling and Care

Appointment Request

Custom header text for registration page

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Please select a Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you need immediate emergency assistance, please call 911 now!

Insurance:

Insurance Company Name:

Member #:

Group #:

Coinsurance (%):

Copay:

Submit

Cancel

Appointment Request

Custom header text for registration page

Personal Information

First Name:* Middle Name: Last Name:* Date of Birth:* Gender of Legal Record:* Male Female

Contact Information

E-mail:*

Phone

Type:*
Number:*

Address

Type:* Street Address: Line2: City: State:
Zip Code:

Please Select a Provider:

Please explain the reason you are seeking help at this time:

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

Insurance

Insurance Company Name: Member #:

Group #: Coinsurance (%): Copay:

Submit

Cancel

Clinic Address

1 West 10th Street Line 2
Shawnee, OK 74801-6801

Clinic Phone No.

(405) 275-2222

Billing Phone No.

(405) 275-2222

Business Hours

Monday thru Friday by appointment only.