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!!!
*
0/20
SMS Text Messaging Opt-In
By checking this box, I consent to receive a reply to this request in the form of SMS text messaging from Indy Child Therapist. Reply STOP to opt-out. Reply HELP for support. Message and data rates apply. Messaging frequency may vary. Visit https://indychildtherapist.com/notice-of-privacy-policies/ to see our privacy policy and our Terms of Service.”
Submit
Should be Empty: