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Legal Name (First/Last)(required)

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Date of Birth (MM/DD/YYYY)(required)

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Legal Gender(required)

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Contact Number(required)

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Contact Email(required)

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Full Mailing Address(required)

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Parent/Guardian Name

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Preferred Source of Payment(required)

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Primary Insurance Name (required)

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Primary Insured Name (required)

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Primary Insured DOB (YYYY-MM-DD)(required)

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Secondary Insurance Name (If Applicable)

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Secondary Insured Name (If Applicable)

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Secondary Insured DOB (If Applicable) (YYYY-MM-DD)

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Preference of Therapist:(required)

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Select Preferred Service:(required)

No Preference Virtual In-Person

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Select Preferred Therapy:(required)

Individual Couple Family Group

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Select Preferred Days for Appointment:(required)

Monday Tuesday Wednesday Thursday Friday Any day/No Preference

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Select Preferred Times for Appointment:(required)

8am-12pm 12-6pm Anytime/No Preference

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Presenting Issues (Select all that apply):(required)

Relational Issues Anxiety/Worry Personality Disorders Family Conflict Weight Loss Depression Faith/Spirituality Divorce Peer Relationships Impulse Control Disorders Self-Esteem Grief Life Transitions Trauma Behavioral Issues Abuse Marital/Premarital Issues Communication Coping Skills Testing/Evaluation Emotional Disturbance Codependency Other

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Location

10475 Crosspoint Blvd, STE 250, Indianapolis, IN 46256

Hours

Monday—Friday
9am — 9pm

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