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Home
Who We Are
Providers
Credentials
What We Do
Forms/Portal
New Patients
Referrals
Credit Card On File
FAQs
General Information
Medication Management
Testing Services
Resources
Blog
Suggested Reading
Crisis Resources
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Referrals
New Patient Referral
Patient's Name:
(Required)
First
Last
Patient Date of Birth:
(Required)
Month
Month
1
2
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5
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9
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11
12
Day
Day
1
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31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1950
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1948
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1946
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1943
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Parent/Guardian Name (if applicable)
Parent/Guardian Phone
Parent/Guardian Email
Office Location
Fayetteville
Rogers
Telehealth
Services
Medication Management
Therapy/Counseling
Psychological Testing
Telehealth
Specific Provider Requested
Other
Is the patient a minor?
(Required)
Yes
No
Your name
(Required)
If you're filling out the form for a minor. Note that only custodial parent or legal guardian may seek treatment for a minor.
First
Last
Additional Patient Insights/Notes
(Required)
Please provide us with any additional information you feel necessary.
Referring Provider Name:
(Required)
Reason for Referral
(Required)
Please include the following when submitting this form.
Face sheet including insurance information
(Required)
Max. file size: 128 MB.
Current medications & problem list
(Required)
Max. file size: 128 MB.
Instagram
This field is for validation purposes and should be left unchanged.
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