First Name *

Preferred/Chosen Name

Last Name *

Preferred Pronouns

Email *

Please check your spam folder for an email from "Aspen Ridge Mental Health" for a code!

Phone *

Date of birth *

Parent/Legal Guardian Full Name

Parent/Legal Guardian Phone Number

What is your relationship with the client? *

If you are a provider, what organization are you from?

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? *

Payment Type *

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

PLEASE NOTE: Once you submit this webform, the following scheduling page won't let you input insurance information again upon scheduling. No worries about this - We will have your insurance information here and it will allow you to input it in paperwork once your appointment is confirmed!

Secondary Insurance for Services

Do you have an EAP you'd like to use with your benefits? *

EAP's will be accepted if possible. Please inform our team of a desire to use one right away!

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)

Please note: If you do not upload an insurance card here, your appointment may need to be rescheduled or cancelled if we're not able to verify insurance prior to the first appointment. Our team will reach out to confirm billing information if left blank!

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.