Contact Us Phone: (405) 242-5305 Fax: (405) 242-5345 Email: therapy@familysolutionsok.com More About FSC Clinical Interns Clinical Intern Appointment Request You may use the following form to schedule an appointment with our Clinical Intern Devin Sellers. To protect your privacy, all responses will be via phone. Thank you! Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Requesting Services for:* Individual Counseling Child/Adolescent Couples Counseling Family Counseling Sliding Scale Fee Range* Under $30,000- $45 $30,000-$50,000- $55 $50,000-$100,000- $65 Over $100,000- $75 Email* Phone*Can we leave a message on your phone?Choose OneYesNoBriefly describe why you are seeking services:*This form is not a confidential or “HIPAA-compliant” way to contact us. Please do not send confidential information through this form.Sign up for our newsletter Check the Box to Receive our FSC NewsletterFamily Solutions Counseling respects your privacy and we do not tolerate spam and will never sell, rent, lease or give away your information (name, phone, email, etc.) to any third party. Nor will we send you unsolicited email. After completing this form, our front office will contact you to schedule your appointment. Thank you!CAPTCHA
