Referral Criteria:

For Inpatient Families

  • Must reside 30 miles or further from Tulsa
  • Must be inpatient in one of the Tulsa area hospitals

For Outpatients

  • Must reside 50 miles or further from Tulsa
  • Must be accompanied at HHT by a full-time caregiver
  • Must be receiving outpatient treatment daily or at least 3 times per week

Patient Name(required)

Guest Name(required)

Family's Phone Number(required)

Referring Hospital(required)

Hospital Floor/Room #(required)

Date(s) Requested(required)

Estimated Length of Stay(required)

Family's Home Address, City/ST(required)

Down Stairs REQUIRED?(required)

Would family like to use Day Room?(required)

Does family have their own transportation?(required)

Date of Referral(required)

Referring Case/Social Worker Name(required)

Case/Social Worker Phone Number(required)

Additional Information

Your Name (required)

Your Email (required)

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