Request an Appointment

Request an Appointment

New clients can complete this short form to request an appointment. Our intake team will contact you via phone and/or email with 48 hours (typically within a business day). If you prefer to schedule a session over the phone, please call (501) 777-5969.
Please Select a Therapist *
Client Legal Name *

First Name Last Name
Client Preferred Name
Client Date of Birth *

Month Day Year
Client Age *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Preferred Contact Method
Preferred Location
How did you hear about us?

Google Psychology Today Facebook Doctor, Therapist, Hospital, Clinic
Please specify Doctor, Therapist, Hospital, Clinic that referred you (if applicable)
Briefly describe why you are seeking counseling or provide other comments
Not Required.
Insurance or Self Pay

Use my insurance if possible (Complete section below) Self Pay - Paying with Cash/Check/Card (Skip section below) I don't know/need more information

Insurance Information
Please complete this section to expedite the intake process if you would like to use your insurance. Our intake team most likely will be able to provide an accurate estimations of eligibility of benefits. Please be aware, we do not guarantee insurance coverage and can only give estimations, therefore it is very important that you find out exactly what mental health services your insurance policy covers.

Visit www.argentacounseling.com to see if our therapists take your insurance.
We do not accept Medicare, Medicaid, ARKids, Tricare, or any Employee Assistant Programs.
Primary Insurance Company
Member/Policy ID
Policy Holder's Full Name on Card
Policy Holder's Date of Birth

Month Day Year
Date
Upload a photo of your Insurance Card

Browse Files
This can help speed up the intake process., but Not Required at this time. Cancel of
Upload a photo of your Drivers License

Browse Files
This can help speed up the intake process., but Not Required at this time. Cancel of
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