New Patient Intake Form (Therapy)

Utah Virtual Office Inquiries Only

Are you seeking services because they are required or mandated in any way?
Are you currently involved in a domestic violence situation?
What is your risk of harming self?
Are you willing to put a credit or debit card on file?
It is the organization's policy to have a card on file. Even if it will not be charged (includes Medicaid clients)
Are you going to be using an HSA or FSA card for payments?
Are you located in Utah?
Clients of ARMH Utah must be residing and present in the state of Utah at the time of services.
Please let us know if you are formally diagnosed with any of the following disorders
Primary Insurance for Services
Our base rate for out of network therapy services start at $225 for the first appointment and $175 for each appointment after that.
Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)
Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)
How did you hear about us?

I agree to terms & conditions provided by the company. By providing my information, I agree to receive follow up messages from the organization.