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- Providers
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What We Do
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FAQs
Resources
Contact Us

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Request an Appointment

New patients only, please fill out the form below.

Please give us a call if you have any questions about this form or the services we offer.

479-443-5575 ext. 1

Step 1 of 4

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URL

This field is for validation purposes and should be left unchanged.

If you are experiencing a life threatening emergency please call 911 or proceed to the nearest emergency room for immediate assistance or call 988 for the Suicide and Crisis Lifeline

What services are you requesting? (You can select more than one)(Required)

Medication Management (Starting new med or managing current)

Therapy/Counseling (Talk therapy, EMDR, CBT, etc.)

Testing/Evaluation (ASD, ADHD, LD)

Medication Management

Is there a specific Med Management provider you would like to see?

Yes

No

Please select your preferred Medication Management provider:

Are you seeking treatment specifically for ADHD?(Required)

Yes

No

Therapy

Is there a specific Therapy provider you would like to see?

Yes

No

Please select your preferred Therapy provider:

Testing

What would you like to be evaluated for? (Select all that apply)(Required)

Autism

ADHD

Learning Disabilities

Is there a specific Testing provider you would like to see?

Yes

No

Please select your preferred Testing provider:

Select Preferred Visit Type

No preference

In-person only

Telehealth only

Telehealth and in-person

Which location do you prefer?

No preference

Fayetteville

Rogers

Telehealth only

Do you have a gender preference for the provider(s) you see?

Describe the reason you are seeking help or services(Required)

Please provide us with an in-depth explanation of why you are wanting to be seen.

Have you had mental health treatment in the past? (Therapy, Medication Management, or Testing)(Required)

Yes

No

Please list where and when

Are you experiencing any of the following symptoms? Please select all that apply.(Required)

Feeling down or depressed

Unable to enjoy activities

Loss of interest in activities

Problems with sleep

Concentration difficulties

Forgetfulness

Changes in appetite

Fatigue

Racing thoughts

Impulsivity

Increased risky behavior

Increased libido

Decreased libido

Excessive energy

Suspiciousness

Increased irritability

Crying spells

Excessive guilt

Excessive worry

Anxiety attacks

Hallucinations

Avoidance

Thoughts of self-harm

Current Medications

Please list all of the medications that you're currently taking. Please add each medication as a separate line. You can use the "plus" icon to add a new line.

Medication

Dosage

Patient's Legal Name(Required)

First Last

Preferred Name

Is the patient a minor?(Required)

Yes

No

Patient Date of Birth(Required)

Month

Day

Year

Patient Gender(Required)

Male

Female

Other

Please Specify

Name of parent/guardian

First Last

Patient Phone Number: (Parent/Guardian number if patient is a minor)(Required)

Email Address(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about us?(Required)

Friend or family

Google / search engine

Google Maps / Apple Maps

Social media

Online ad

Psychology Today or similar directory

Insurance company directory

Magazine ad/article

Primary Care Provider (PCP / Pediatrician)

Psychiatrist / psychiatric nurse practitioner

Therapist / counselor / psychologist

School Counselor / School Staff

Other Healthcare provider (OB-GYN, neurologist, etc.)

Hospital / urgent care / ER

Mental health treatment program (inpatient, outpatient)

Returning patient

Other

Referring person or organization

If applicable, please list the name of provider, clinic, school, program, or hospital.

Do you have insurance?(Required)

Yes

No

Policy Holder's Name(Required)

First Last

Policy Holder's Date of Birth(Required)

Month

Day

Year

Policy Holder's Employer

Insurance Company Name(Required)

Aetna

Ambetter

AMCO / Stratose / Zelis

Blue Advantage

Blue Cross Blue Shield

Cigna / Evernorth

Coventry

Employer's Health Coalition (EHC)

Government Employees Health Administration (GEHA) - OUT OF NETWORK

Health Advantage

Key Benefit Administrator

Municipal Health Benefit Fund

QualChoice

Tricare

UMR - OUT OF NETWORK

UMR University of Arkansas

United Healthcare - OUT OF NETWORK

Other - Please Specify

Phone number for Mental Health, Customer Service, or Eligibility/Benefits

You can find this on the back of the card.

ID / Policy #(Required)

Group / Plan / Division #

Do you have secondary insurance?(Required)

Yes

No

Secondary Insurance Policy Holder's Name(Required)

First Last

Secondary Insurance Policy Holder's Date of Birth(Required)

Month

Day

Year

Secondary Insurance Policy Holder's Employer

Secondary Insurance Company Name(Required)

Aetna

Ambetter

AMCO / Stratose / Zelis

Blue Advantage

Blue Cross Blue Shield

Cigna / Evernorth

Coventry

Employer's Health Coalition (EHC)

Government Employees Health Administration (GEHA) - OUT OF NETWORK

Health Advantage

Key Benefit Administrator

Municipal Health Benefit Fund

QualChoice

Tricare

UMR - OUT OF NETWORK

UMR University of Arkansas

United Healthcare - OUT OF NETWORK

Other - Please Specify

Secondary Insurance phone number for Mental Health, Customer Service, or Eligibility/Benefits

You can find this on the back of the card.

Secondary Insurance ID / Policy #(Required)

Secondary Insurance Group / Plan / Division #

PCA Resources, PA is an independent company that provides billing and administrative services to health care providers. All health care providers that use PCA are independent contractors and are not the agents or employees of PCA Resources, PA. Please note that the information contained within this website is provided for informational and educational purposes only. The use of this website does not imply or establish any type of doctor/patient relationship. No diagnosis or treatment is being provided by the use of this website.

PCA NWA mental health services - CitiScapes Magazine Best of Northwest Arkansas badges from 2009 to 2024, highlighting 16 consecutive wins for Best Mental Health Clinic.

PCA NWA mental health services - Half tree with branches and leaves on the left, merging with a stylized half brain on the right, both in shades of blue.

Home
About
Our Providers
What We Do
New Patients
Referrals
FAQ
Blog
Resources
Careers
Contact

Home
About
Our Providers
What We Do
New Patients
Referrals
FAQ
Blog
Resources
Careers
Contact

Home
About
Our Providers
What We Do
New Patients
Referrals
FAQ
Blog
Resources
Careers
Contact

Home
About
Our Providers
What We Do
New Patients
Referrals
FAQ
Blog
Resources
Careers
Contact

Fayetteville

Building One
1 W. Sunbridge Drive
Fayetteville, AR

Building Two
6 W. Sunbridge Dr.
Fayetteville, AR 72703

Building Three
86 W. Sunbridge Dr
Fayetteville, AR 72703

Rogers

5434 W. Walsh Lane,
Suite #100
Rogers, AR

988 Suicide and Crisis Lifeline (Text or Call 988)

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