High-altitude tectonic zones are active areas for geothermal groundwater, and the elevated arsenic content within them has emerged as a significant resource and environmental concern. This study selected the Gonghe-Guide Basin in the northeastern Qinghai-Tibet Plateau as the subject of investigation, employing field tests of geothermal water samples, hydrochemistry, thermodynamic simulations, and statistical methods to explore the forms, distribution, and sources of arsenic in geothermal groundwater. The research data indicates that the geothermal groundwater in the area displays weak alkalinity, medium to high mineralization, with the primary hydrochemical types being SO4-Cl·Na and Cl·Na. Arsenic concentration shows a significant negative correlation with Cl− and a positive correlation with water temperature and DO. Thermodynamic simulations suggest that the predominant form of arsenic is As5+. Rock weathering, evaporative concentration, and ion-exchange adsorption collectively shape the hydrochemical characteristics of the study area, laying the environmental groundwork for the formation and migration of arsenic. Notably, the ion-exchange between sodium ions and calcium and magnesium ions significantly impacts the arsenic concentration. This study provides insights into the behavior, forms, and origins of arsenic in geothermal groundwater and offers a reference for similar research in other geothermally active regions.