Child Guidance Appointment Request

Meet with a Child Guidance audiologist, behavioral health specialist, child development specialist, or speech and language pathologist.

"*" indicates required fields

If you are making a referral on behalf of a client, please provide your name, agency and phone number

Child's Name*

First Last

Child's DOB*

Parent/Guardian's Name*

First Last

Parent/Guardian's Email*

Family's Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Area of concern/service requested*

Please check all that apply.

Hearing

Speech / Language

Autism

Behavior

Sleep / Toilet Training / Eating

Developmental Screening

Preferred location

Not all services available at all locations.

James O. Goodwin Health Center 5051 S. 129th E. Ave.

Central Regional Health Center 315 S. Utica Ave.

North Regional Health and Wellness Center 5635 N. MLK Jr. Blvd.

Phone

This field is for validation purposes and should be left unchanged.

We have 10 locations across Tulsa County that offer a variety of services to help you and your family stay healthy.

Food