New Client Request
By completing the form below: I understand that the use of email is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and consent to Indy Child Therapist, LLC communicating to me, by non-secure email at the address provided, Protected Health Information (PHI) related to the scheduling of therapy sessions and/or other appointments.
Parent First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Who Referred You?
Payor Info
Please Select
Self Pay
Aetna
Anthem
Caresource
Cigna (we do not take)
IU Health
United
UMR
Medicaid (we do not take)
Tricare (we do not take)
Client Information- Please include your child's age and gender as well as a short description of the problem. PLEASE DO NOT INCLUDE NAME OR DOB!!!
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