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Bina has previously worked as a nurse for over 10 years. She has been certified as the TMS technician/coordinator. She has a passion for helping others. Her goal is to offer hope and support to those suffering with depression. She enjoys seeing the positive results of TMS and continues to positively change the lives of many. 

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Patient Forms

We've provided forms below that you'll need to complete before your first appointment. It will take you about 45 minutes to complete these forms.

All Forms

All Patient Forms for the New Patient-Adult

If you're a new patient then these are the only forms you need to download and complete.

All Patient Forms for the New Patient- Child

If you're a new patient then these are the only forms you need to download and complete

All Patient Forms for the New Patient- Counseling

If you're a new patient for counseling then the only forms you need to download and complete

Individual Forms

Controlled Substance Policy

If provider prescribes a controlled substance medication as part of a treatment plan

Authorization to receive Protected Health Information

With this form you give us authorization to receive health information from another facility or provider so we can provide you the best of care

Authorization to Release Protected Health Information

​With this form you give us authorization to release your protected health information to another facility or provider.

Consent for communication

This is another release of information form. This form is used to release information to family members and friends that may be involved in the care of the patient.

Informed Consent for Telemental Health services

If Telemental health services are needed.

General Information about AR Psychiatric and Counseling Center

​This form outlines general information about ARPCC to include clinic hours, types of appointments, our policy on late or missed appointments, insurance and payments, record keeping and more.

Notice of Privacy Practices

This form describes how medical information about you may be used and disclosed and how you can get access to this information.

Social Media Policy

This document outlines our office policy related to the use of social media.

Update Medical History - Adult

This form updates medical and psychiatric issues during follow up appointment of adults

Update Medical history - Child

This form updates medical and psychiatric issues during follow up appointment of children and adolescents