Referral Request

1
Are you ready to find a therapist that looks like you?
2
Name* This field is required.
First Name
Last Name
3
Email
example@example.com
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Preferred Contact Method (email/sms)
6
Ethnicity you associate withAfrican American, Asian, etc
7
Preferred therapist ethnicityAfrican American, Asian, etc..
8
Preferred Therapist Gender* This field is required.
9
Issues/symptoms* This field is required.Why do you feel the need for Therapy?
10
Have you ever been diagnosed?* This field is required.i.e: Anxiety, Depression, Eating Disorder, Schizophrenia, ADHD,etc
11
Have you gone to therapy before?Do you remember the year you were diagnosed?
12
Do you have the desire to harm yourself, or others?(Explain)In the event of an emergency please contact your local crisis center/911
13
Are you available to schedule a virtual call to discuss your needs in more depth?* This field is required.
Yes
No
14
AppointmentSelect a date for our one on one :)
15
Take Photo* This field is required.Please take a photo of the front of your government issued ID (driver's license, state issued ID, passport)
16
Take Photo* This field is required.Please take a photo of the back of your government issued ID (driver's license, state issued ID, passport)
17
Therapist Connect FeeThere is a fee for this personalized service. You speak with a Nikole directly as she connects you with the best match therapist for your area.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Therapist Connect FeeThe price covers a 15-minute virtual call along with a personalized pairing of a Mental Health Professional who has been verified through Argh U Mad's LLC. overage at arghumad.com. The price does not cover the expenses and or copay required by the licensed Professional Mental Health provider that has been hand-selected. If your state is not covered, please allow 7 business days for a match. If a match is not made in that time you will receive a 100% discount.
$30.00+Edit
Back
Total cost $0.00
18
Invoice ID
19
Terms and Conditions* This field is required.I give Argh U Mad LLC consent to contact my health insurance for a list of providers in the event Argh U Mad LLC's therapist does not accept my insurance carrier. Argh U Mad LLC will provide a copy of this consent to the licensed Mental Health Care Professional to establish initial scheduling and or report unexcused absences and or missed appointments. I agree to honor my scheduled therapist appointments once paired with a Licensed Mental Health Professional matched Argh U Mad LLC. Please email info@arghumad.com if your state is not highlighted with a licensed health professional to treat in your area. You agree to contact Argh U Mad 24 hours in advance to reschedule your scheduled appointment with your licensed Mental Health Professional. By clicking agree you verify that you are the party in the government-issued ID required above. If the name and picture do not match the virtual caller forfeits their therapist matching fee of $30.00
20
Do you have insurance?If you don't that's fine! Almost all of our therapists accept cash payments. I'll let you know their rates when we meet. It should be no more than $120.00 per hour, that's less than a pair of Jordans or your cell phone bill. Don't cheat yourself, invest in yourself.
YESNO
21
Payment Methods
Debit Or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and submit the form.
Should be Empty: