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
Date of Birth
Are you seeking support for yourself or your child?
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?
Do you have a referral from a Doctor or Clinician?
What type of medical insurance do you have? (Name of Insurance Provider)
Please attach any additional records to assist with intake.
Type any additional information you wish to include.
Should be Empty: