AFF New Patient Form

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Please complete the secure form below to initiate services with Arkansas Families First, LLC.

Email *

Patient Full Name *

Patient DOB (Date of Birth) *

YYYY

Reason for Referral *

Your Full Name *

Relationship to Patient *

Desired Email Address for Scheduling *

Mobile Phone Number for Scheduling *

Text Messaging with Arkansas Families First allows for efficient and convenient scheduling.

By opting in below, you agree to receive SMS messages from Arkansas Families First, LLC. This includes SMS messages for appointment scheduling, appointment reminders, post-visit instructions, lab notifications, and billing notifications. Message frequency varies. Message and data rates may apply. See privacy policy at https://arfamiliesfirst.com/privacy-policy-terms-and-conditions/. Message HELP for help. Reply STOP to any message to opt-out.

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Preferred Clinic Location *

Which service(s) are you seeking? *

Individual or Family Counseling / Behavioral Therapy

Psychological or Developmental Evaluation (Testing)

Psychiatric Medication Management

Group Therapy

Career Testing & Counseling

UAMS ARBEST Traumatic Stress Evaluations

Other:

Required

Which provider(s) would you prefer? *

Primary Insurance *

Insurance Subscriber Name

Home Address of Insurance Subscriber

Insurance ID #

Insurance Group #

Additional Information

Send me a copy of my responses.

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