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  • Clinicians & Staff
    • Clinicians In Training
    • Allison Adams, Psy.D.
    • Alan Bagley, MD
    • Khiela Holmes, PhD
    • Janelle Von Storch, LPC
    • Ivanjo Aldea, M.D.
    • Jason LaGory, Ph.D.
    • Sarah Lindeman Root, PhD
    • Mary Ekdahl, Ph.D.
    • Adam Benton, Ph.D.
  • Services
    • Evaluation and Testing
    • Counseling & Behavioral Therapy
    • Psychiatric Medication Services
    • Telehealth (Visual & Audio)
    • DBT Program (Teens)
    • PEERS Program (Teens)
    • Launch (Young Adults)
    • Parent Workshops
    • Infant and Toddler Mental Health
    • Services For Schools
    • Clinical Training for Providers
      • Student Training Program
      • TF-CBT Consultation Calls
      • DC: Zero to Five Training
      • AFF Book Club
  • Blog
  • Resources
    • Assessment Tools
    • FAQs
    • AFF Patient Portal Login
    • Self-help Resources
      • Books
      • Videos
      • Info Graphics
      • Reward Charts & More
  • Contact Us
    • Referral Form
    • Payment Portal
    • ARBEST Referral Form
    • Group/Class Payments
  • Clinicians & Staff
    • Clinicians In Training
    • Allison Adams, Psy.D.
    • Alan Bagley, MD
    • Khiela Holmes, PhD
    • Janelle Von Storch, LPC
    • Ivanjo Aldea, M.D.
    • Jason LaGory, Ph.D.
    • Sarah Lindeman Root, PhD
    • Mary Ekdahl, Ph.D.
    • Adam Benton, Ph.D.
  • Services
    • Evaluation and Testing
    • Counseling & Behavioral Therapy
    • Psychiatric Medication Services
    • Telehealth (Visual & Audio)
    • DBT Program (Teens)
    • PEERS Program (Teens)
    • Launch (Young Adults)
    • Parent Workshops
    • Infant and Toddler Mental Health
    • Services For Schools
    • Clinical Training for Providers
      • Student Training Program
      • TF-CBT Consultation Calls
      • DC: Zero to Five Training
      • AFF Book Club
  • Blog
  • Resources
    • Assessment Tools
    • FAQs
    • AFF Patient Portal Login
    • Self-help Resources
      • Books
      • Videos
      • Info Graphics
      • Reward Charts & More
  • Contact Us
    • Referral Form
    • Payment Portal
    • ARBEST Referral Form
    • Group/Class Payments
  • Clinicians & Staff
    • Clinicians In Training
    • Allison Adams, Psy.D.
    • Alan Bagley, MD
    • Khiela Holmes, PhD
    • Janelle Von Storch, LPC
    • Ivanjo Aldea, M.D.
    • Jason LaGory, Ph.D.
    • Sarah Lindeman Root, PhD
    • Mary Ekdahl, Ph.D.
    • Adam Benton, Ph.D.
  • Services
    • Evaluation and Testing
    • Counseling & Behavioral Therapy
    • Psychiatric Medication Services
    • Telehealth (Visual & Audio)
    • DBT Program (Teens)
    • PEERS Program (Teens)
    • Launch (Young Adults)
    • Parent Workshops
    • Infant and Toddler Mental Health
    • Services For Schools
    • Clinical Training for Providers
      • Student Training Program
      • TF-CBT Consultation Calls
      • DC: Zero to Five Training
      • AFF Book Club
  • Blog
  • Resources
    • Assessment Tools
    • FAQs
    • AFF Patient Portal Login
    • Self-help Resources
      • Books
      • Videos
      • Info Graphics
      • Reward Charts & More
  • Contact Us
    • Referral Form
    • Payment Portal
    • ARBEST Referral Form
    • Group/Class Payments
AFF FormsDr. Adam Benton2024-08-30T07:54:51-06:00
Forms

New Patient Forms

  • Psychotherapy Agreement
  • Consent to Email (Child and Adult)

  • Either:  Patient Registration Child / Adolescent  Or  Adult Patient Registration

  • Evaluation / Testing Process Information (If Applicable)

  • HIPAA Privacy Notice 

  • Patient Signature Form

Additional Forms

  • AFF Referral FormAFF Referral Form
  • Adult Telehealth Consent

  • Child Telehealth Consent

  • Court Fees Notice
  • Adult Info Request  & Adult Info Release 
  • Child Info Request  & Child Info Release

Main Office

4004 McCain Blvd, Suite 203, North Little Rock, AR 72116

Phone: 501-812-4268

Fax: 501-812-4286

Keep In Touch!

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