Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Text Message Agreement
*
By checking this box, you agree to receive text messages related to your care and appointments from Alleviant Integrated Mental Health. You may reply "STOP" to opt-out at any time. Message and data rates may apply. Message frequency will vary. Text "HELP" to 501-424-0585 for assistance. Learn more on our
Privacy Policy and
Terms of Use pages.
I agree
Email
*
Insurance Provider
*
Aetna
Allwell
Ambetter
AR BlueCross BlueShield
Arkansas Municipal Health
BlueCross BlueShield HMO Plus
BlueCross BlueShield of Texas
Cigna
Federal BlueCross BlueShield
GEHA
Magellan
Medicare
Medicaid
Medipac Advantage
Optum (UMR)
QualChoice
Railroad
Self-Pay
TriCare
United Healthcare (UMR)
Not Applicable
Policy Holder Name
*
First Name
Last Name
Policy Holder Date of Birth
*
MM
DD
YYYY
Requested Clinic Location
*
Bentonville, AR
Bryant, AR
Conway, AR
Fayetteville, AR
Fort Smith, AR
Jonesboro, AR
Little Rock, AR
North Little Rock, AR
Rogers, AR
Henderson, NV
Telebehavioral Health
Requested Services
*
Psychiatry
Therapy
Medication Management
Transcranial Magnetic Stimulation (TMS)
Ketamine Therapy (IV & Spravato)
IV Wellness Therapy
Spectral EEG with Consult
Pharmacogenetic Testing
Health Coaching
Performance Optimization
Other
Additional Notes
How Did You Hear About Us?
*
Social Media (Facebook, Instagram, etc.)
TV Commercial
DIgital Banner Ad
Email Newsletter
Community Event or Seminar
Flyer or Print Ad
Alleviant Employee or Team Member
Referral from Friend or Family Member
Referral from Doctor or Therapist
Other (please specify)