Arp-Howard Counseling, LLC

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

State

Select the state you live in

Reason for care

Goals and hopes

In one or two sentences, please let me know what you are hoping to get out of services with me.

Therapy Services

Of the services I provide, which are you interested in?

Individual Therapy Couples Therapy Family Therapy Parenting Support ADHD Support Group Business Consultation

Administrative

Referral source

How did you hear about my practice?

Telehealth

My practice is conducted 100% via Telehealth. Does this work for you?

Yes

Billing & Payment

Fees and insurance

How do you plan to pay for services? I ask here because I work to keep my practice balanced in terms of income sources.

By utilizing my in-network benefits with Moda. By utilizing my in-network benefits with Pacific Source. By utilizing my in-network benefits with Cigna. By utilizing my in-network benefits with Pacific Source. By paying your $185 out of pocket rate, and then utilizing out of network benefits with my insurance plan (not listed above) for partial reimbursement.. By paying your $185 out of pocket rate, and not utilizing insurance.

Client Preferences

Appointment time

What is your available time to meet during Sarah's clinical hours (M-F 8:30-2:30)?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.