Submissions Portal

You have been redirected to our Submissions Portal. Below you will find the forms needed for you to review, sign, and submit prior to your scheduled appointment. Please read the instructions below to download the required documents, as well as any other documents from the ones listed that may apply. You are also required to upload a picture of your State or Government Issued ID (front and back) in order to verify signatures. If it applies, please upload a copy of your Insurance Card (front and back), unless you are a Lyra Health client.

Note*: Incomplete forms may cause for your appointment to be canceled. Due to the demand for our therapists, client are allowed to reschedule once, but will likely no longer be rescheduled after a second cancelation out of respect for our therapists limited schedule and the other clients also trying to get in. Thank you for your understanding in this matter, and for further questions please call (479) 709-2369.

PERSONAL INFORMATION:

First and Last Name:

Date of Appointment

IMPORTANT: Please attach signed required documents below, as well as any other supporting document. You do not have to use every upload field in order to submit. You are allowed to come back and upload through this portal as often as needed. Only submit what is needed.

Consents and Therapeutic Contract (required)

Upload File

TeleMental Health Consent (required)

Upload File

Authorization and Request for Release of Information

Upload File

Face Sheet (filled out and signed; required)

Upload File

State/Federal Issued ID (front and back; required)

Upload File

Health Insurance Card (front and back; required)

Upload File

Once you have uploaded the required documents please click the "submit" button in order to have them sent to our Administrative Assistant. Please allow 1 to 2 business days in order to receive an email, call, or text verifying we have received the documents needed in order to conduct the initial session.

Thanks for submitting! We will attempt to contact you within the next 1 to 2 days in order to confirm we have received documentation.

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REQUIRED DOCUMENTS

Please download the following two (3) required forms. Review, fill out, initial, sign, upload above.

SUPPORTING DOCUMENTS

The following are documents specifically to authorize certain persons or entities permission to a part of your treatment team. Please download, fill out, and sign the Authorization and Release of Information forms that apply. The first is for partner, spouse, or child (above 18 years of age), and the second is for your PCP or other entity. The forms are pre-filled.

ROI (partner, spouse, family)

Download

ROI (PCP or other entity)

Download

* The forms you are downloading are the intellectual property of Bryant Prieto and New Leaf Counseling of the River Valley, Inc. It is expressly understood that by downloading these forms you will be utilizing them for their intended purpose, which is simply to begin services with New Leaf Counseling of the River Valley, Inc. and its providers. Violators utilizing these forms for purposes outside of their intended use (i.e., initiating services with New Leaf Counseling and its providers) can and likely will be prosecuted.

Contact Us!

If you have questions about self-pay rates, services, etc. feel free to ask here. Please leave your name, contact email address, and a good phone number that we can call back. We will try to get in touch with you within 24-48 hours. If you do not get an e-mail back from us within that time frame, please check your junk mail, as many have reported this to be an issue. Thank you.