How Can We Help?
Please complete the following form and a member of our team will follow up within 48 hours. To follow up directly please contact our office at 219-750-9600. Services will take place in person at our clinic located in Merrillville Indiana. You can also visit us at www.superpsychedsupport.com for more information.
Name of Person Completing form
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Are you seeking support for yourself or your child?
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Self
Child
Children
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If completing form for someone other than yourself, please list their names and date of birth.
Please let us know how we can help. Why are you seeking therapy or counseling support?
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Do you have a referral from a Doctor or Clinician?
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Yes
No
What type of medical insurance do you have? (Name of Insurance Provider)
*
Please attach any additional records to assist with intake.
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