Initial Contact Form

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Select language. Seleccione el idioma.* This field is required.
EnglishEspañol
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Let's start off getting some basic contact information.
First Name
Last Name
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What is the best method for us to contact you? Select all that apply.(You must at least fill in either a phone number or email in the sections below for us to be able to reply to your request)
Phone call
Text
Email
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EmailPlease be aware confidential messages may be sent to the email address you provide.
example@example.com
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Phone NumberPlease be aware confidential voicemails/texts may be sent to the phone number you provide.
Please enter a valid phone number.
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Do you want your sessions to be in person or telehealth (online)? (If requesting Telehealth, please include your email in the contact information. Also, you must reside in the state of Indiana for our clinicians to provide services via Telehealth.)
In Person
Telehealth (online)
Either option
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If in person, where would you want your sessions to be located?
South office (near Greenwood)
North office (near Fishers)
Either location
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Where do you want your sessions to be located?
South office (near Greenwood)
North office (near Fishers)
Either location
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Who will primarily be attending sessions?If you are unsure, we can still help you find your best match no matter what you select.
Individual Adult
Adult Couple
Individual Teen (age 13-17)
Individual Child (age 7-12)
Family
Other
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Is there a specific therapist you are interested in scheduling with?If you select yes, you may choose more than one therapist on the next page. If you select no, we will help match you with your best therapist using additional information you provide to us.
YesNo
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Please select from the options below. You may select more than one and we will be happy to help you choose from your selected options.Please note: Certain clinicians may not be able to accept new clients dependent on their current caseload and may not have office times during your preferred days/times.
Brandy (South office)
Danae (South office)
Daniel (South office)
Ethany (North office)
Jennifer (South office)
Jourdan (South office)
Joel (South office)
John (North and South office)
Kalyn (North office)
Kat (North office)
Lizzie (South office)
Madison (North office)
Megan (South office)
Robyn (South office)
Staci (North office)
Other
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Please select from our North office clinicians below. You may select more than one and we will be happy to help you choose from your selected options.Please note: Certain clinicians may not be able to accept new clients dependent on their current caseload and may not have office times during your preferred days/times.
Ethany
John
Kalyn
Kat
Madison
Staci
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Please select from our South office clinicians below. You may select more than one and we will be happy to help you choose from your selected options.Please note: Certain clinicians may not be able to accept new clients dependent on their current caseload and may not have office times during your preferred days/times.
Brandy
Danae
Daniel
Jourdan (Masters Intern)
Jennifer
Joel
John
Lizzie
Megan
Robyn
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To tell us your primary reason for seeking therapy would you rather select from multiple provided choices or type a brief description?Just a reminder, your answers are confidential and strictly protected by HIPAA standards. We will not share any of your information without your consent.
Multiple ChoiceBrief Description
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What is the primary reason for seeking therapy? Please check all that seem to apply.
Anxiety
Trauma
Feeling Angry
Feeling Depressed
Nightmare / Flashbacks
Sleep Troubles
Shame
Unsafe Behaviors
Grief
Low Self-esteem
Family Tension / Conflict
Parenting concern
Self Harm
Suicidal Thoughts
Hopelessness
Financial Stress
Sexual Difficulties
Religious Concerns
Addiction Concerns
Frequently Feeling Unsafe
Work Stress
Infidelity Concerns
Eating Problems
Eating Disorder-Current or Past
Lack of Trust
Difficulty Controlling Worry
Difficulty Controlling Fear
Difficulty Socializing
Marital Issues
Communication Issues
Custody Problems
Other
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What is the primary reason for seeking therapy?It's ok to simplify your answer, most situations are much more complex than this text box allows. (This form is intended only as an initial contact form. An intake form will be sent once an appointment is made so you will be able to include further details).
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Please Read: As of January 1, 2024 our rates for service will be $145 per 50 minute session. We are an out of network mental health provider. We do not directly bill or file claims with any private or public insurance companies, which means we do not accept insurance. With that, the rate is due at the end of each session. HSA or Flex Spending Accounts are accepted. Many of our clients who have out of network coverage request a monthly Superbill which can be submitted to their insurance company for reimbursement. Call the number on the back of your insurance card to find out if they accept Superbills and how you can easily submit an out of network claim.* Reimbursement rates are dependent on your insurance plan guidelines. Any student intern rate, which is a reduced rate, is not reimbursable by insurance.
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Information you need to know if you are considering using your health insurance to pay for therapy and some reasons we do not accept insurance. If you have a high deductible insurance plan, you will be paying for services out of pocket even through an in-network provider. Before your claim will be covered, insurance companies require that you be given a "mental health diagnosis", that may remain on your medical record indefinitely. There have been occasions when a clinical diagnosis to your insurance has resulted in persons experiencing difficulty in obtaining life, medical or disability insurance. The insurance company will have access to (all) sensitive information shared (i.e. sexual history and drug use). If confidentiality is important to you, it may be compromised by using your insurance. The insurance company has control over how often, how long, and even if you may see a (particular) therapist, independent of using your insurance benefits. Marriage or relationship counseling is typically not covered by insurance. *These above conditions do not apply if filing an out of network claim for reimbursement through your insurance.
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How to Submit an Insurance Claim It is important to know how to submit a claim to your insurance company. While this process is common it can be new to some people. Following these steps can help you get reimbursed for any visits you have paid for out-of-pocket and ensure your mental health bills are paid as promptly as possible. Step 1: Ask Us for your Superbill To file a claim, you need to obtain an itemized bill, or “Superbill,” from your provider (It's important to know that our office will email Superbills once a month during a predetermined time. Superbills are not sent out after each session.) This bill will list every service you received from the prior month, along with the cost and a special code the insurance company will need to pay your claim. There must be a billable diagnosis (an acceptable diagnosis by your insurance company) to receive reimbursement. Please discuss with your clinician if you have any questions about your diagnosis. Step 2: Call your Insurance Company When you have your Superbill in hand, give your insurance company a call using the phone number on the back of your insurance card. Let them know you will be sending in a claim and ask for methods to submit your Superbill for reimbursement. Be sure to ask them if there are any additional documents that may need to be sent and how long until you can expect the claim to be paid. Step 3: Make at Least One Copy As a preventative measure, it is always a good idea to make copies of all documents you are submitting with your entire claim, before sending it to your insurance company. Step 4: Send You may be expected to mail in your claim, but often you may submit your documents online, by email, or fax. Your insurance company will inform you of acceptable options. Step 5: Wait If you do not receive payment for your claim within the time frame given to you, contact your insurance company, and let them know. As always, be sure to contact your insurance company directly if you have questions about filing a claim, claim status, or your benefits.
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Late Cancellation and No Show Policy: A fee of $70 will be charged for any session canceled with less than 24 hour notice. For any sessions that are a no show with no communication, the fee assessed will be for the full session rate of $145.
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What days and times would you be able to schedule sessions? (Please note: our clinicians work varying days and hours. We will do our best to offer availability as close to your request as possible.)
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¿Cómo te llamas?
First Name
Last Name
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¿Cuál es el mejor método para que nos comuniquemos con usted? Seleccione todas las que correspondan.
Llamada telefónica
Texto
E-mail
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E-mailTenga en cuenta que es posible que se envíen mensajes confidenciales a la dirección de correo electrónico que proporcione.
example@example.com
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Número de teléfonoTenga en cuenta que es posible que se envíen mensajes de texto/correos de voz confidenciales al número de teléfono que proporcione.
Please enter a valid phone number.
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¿Quieres que tus sesiones sean presenciales o telesalud (online)?
En Persona
Telesalud (online)
Cualquiera de las dos opciones
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¿Quién asistirá principalmente a las sesiones?
Adulto individual
Pareja adulta
Adolescente individual (edad 13-17)
Niño individual (edad 7-12)
Familia
Otro
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¿Cuál es la razón principal para buscar terapia?
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Nuestras tarifas por servicio son de $145 por sesión de 50 minutos. Somos un proveedor de salud mental fuera de la red. No facturamos directamente a ninguna compañía de seguros pública o privada. Muchos de nuestros clientes presentan reclamos fuera de la red a su compañía de seguros para obtener un reembolso. Llame al número que figura en el reverso de su tarjeta de seguro para averiguar cómo puede presentar fácilmente un reclamo fuera de la red.* Las tasas de reembolso dependen de las pautas de su plan de seguro.
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Información que necesita saber si está considerando usar su seguro de salud para pagar la terapia y algunas razones por las que no aceptamos seguros. Si tiene un plan de seguro con deducible alto, pagará los servicios de su bolsillo incluso a través de un proveedor dentro de la red. Antes de que se cubra su reclamo, las compañías de seguros requieren que se le dé un "diagnóstico de salud mental", que puede permanecer en su registro médico indefinidamente. Ha habido ocasiones en que un diagnóstico clínico de su seguro ha dado lugar a que las personas experimenten dificultades para obtener un seguro de vida, médico o de discapacidad. La compañía de seguros tendrá acceso a (toda) la información confidencial compartida (es decir, historial sexual y uso de drogas). Si la confidencialidad es importante para usted, puede verse comprometida al usar su seguro. La compañía de seguros tiene control sobre la frecuencia, la duración e incluso si puede ver a un terapeuta (en particular), independientemente del uso de los beneficios de su seguro. El asesoramiento matrimonial o de relaciones generalmente no está cubierto por el seguro. *Estas condiciones anteriores no se aplican si presenta un reclamo de reembolso fuera de la red a través de su seguro.
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Cómo presentar un reclamo de seguro. Es importante saber cómo presentar un reclamo a su compañía de seguros. Si bien este proceso es común, puede ser nuevo para algunas personas. Seguir estos pasos puede ayudarlo a obtener un reembolso por cualquier visita que haya pagado de su bolsillo y garantizar que sus facturas de salud mental se paguen lo antes posible. Paso 1: Pídanos su Superfactura Para presentar un reclamo, debe obtener una factura detallada, o "superfactura", de su proveedor. Esta factura enumerará todos los servicios que recibió, junto con el costo y un código especial que la compañía de seguros necesitará para pagar su reclamo. Debe haber un diagnóstico facturable (un diagnóstico aceptable por su compañía de seguros) para recibir el reembolso. Hable con su médico si tiene alguna pregunta sobre su diagnóstico. Paso 2: llame a su compañía de seguros Cuando tenga su súper factura a la mano, llame a su compañía de seguros usando el número de teléfono que se encuentra en el reverso de su tarjeta de seguro. Hágales saber que enviará un reclamo y solicite métodos para enviar su superfactura para su reembolso. Asegúrese de preguntarles si hay algún documento adicional que deba enviarse y cuánto tiempo hasta que pueda esperar que se pague el reclamo. Paso 3: Haga al menos una copia Como medida preventiva, siempre es una buena idea hacer copias de todos los documentos que presente con su reclamo completo, antes de enviarlo a su compañía de seguros. Paso 4: Enviar Es posible que se espere que envíe su reclamo por correo, pero a menudo puede enviar sus documentos en línea, por correo electrónico o por fax. Su compañía de seguros le informará sobre las opciones aceptables. Paso 5: Espere Si no recibe el pago de su reclamo dentro del plazo que se le dio, comuníquese con su compañía de seguros e infórmeles. Como siempre, asegúrese de comunicarse directamente con su compañía de seguros si tiene preguntas sobre cómo presentar un reclamo, el estado del reclamo o sus beneficios.
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¿Qué días y horas podría programar las sesiones?
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Is there anything else you want to tell us or any other questions you have at this time?¿Hay algo más que quieras decirnos o alguna otra pregunta que tengas en este momento?
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