Appointment Request Indianapolis Please enable JavaScript in your browser to complete this form.12Client Name *FirstLastClient Email *Client Phone *Location *IndianapolisMemphisLeominsterWichitaKissimmeeSt CloudServices Needed *Case ManagementIndividual TherapyFamily CounselingGroup TherapyMedication ManagementPsychiatric EvaluationSession Type *In PersonIn Person – GroupTelehealthBoth – HybridInsurance Provider *Self PayAetnaAmbetterAnthem Blue Cross/ Blue ShieldCignaMedicareIndiana MedicaidMHSMDWiseMagellanUnited HealthcareWellcare/Allwell*Please call 317-638-8114 for questions regarding insurance providers Policy NumberPolicy Holder's NameFirstLastWhy are interested in therapy? *I am depressedI am anxious/overwelmedI’ve been diagnosed with a mental disorderI’m battling addictionI am grievingI want to improve self confidenceI am struggling with relationshipsI experienced traumaRecommended (by doctor, family or friends)OtherNextPreviousSubmit
