Texas Virtual Therapy Intake Form

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

Are you seeking services because they are required or mandated in any way? *

Are you currently involved in a domestic violence situation? *

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 located in Texas? *

Clients of ARMH Texas must be residing in and present in Texas at the time of services.

Are you going to be using an HSA or FSA card for payments? *

What service type(s) are you interested in? *

Individual Therapy

Couple's Therapy

Family Therapy

Formal diagnoses *

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.

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? *

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