First Name *

Preferred/Chosen Name

Last Name *

Pronouns

He/Him

She/Her

They/Them

Email *

Phone *

Date of birth *

Parent/Legal Guardian Full Name

Parent/Legal Guardian Phone Number

Which ARMH location are you requesting to receive services from?

Patients must be residing and physically present in the state in which they are receiving services at the time of their appointment(s).

What therapy/coaching services are you interested in? *

Individual Therapy

Couples Therapy

Family Therapy

ADHD Coaching

Group Therapy - Eating Disorder Process Group (18+)

Group Therapy - Binge Eating Disorder Process Group (18+)

Group Therapy - Relationships Therapy Group (18+)

Group Therapy - Queer Process Group (18+)

*ADHD Coaching is NOT ADHD testing. You do not have to be formally diagnosed with ADHD to participate in the program. For ADHD testing inquiries, please use the testing webform.

What is prompting you to seek services with us? *

Primary Insurance for Services *

If you do not have insurance, ask about our sliding scale options.

Secondary Insurance for Services

Insurance Card (Front)

Please upload a photo of the front of your insurance card

Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)

Insurance Card (Back)

Please upload a photo of the back of your insurance card

Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)

How did you hear about us?

Disclaimer

It is our mission to provide the highest quality of care to our patients. We may not be able to provide services to patients that reach out with the following conditions, high risk of suicidality, domestic violence, high risk substance use, or personality disorders such as borderline personality disorder or narcissistic personality disorder. If a patient is in need of a higher level of care, we will provide them with the resources that they need. Court-ordered or mandated services will also result in being referred to another practice that specializes working with legal cases.

By providing my information, I agree to receive follow up messages from the organization.