REQUEST SERVICES

Have questions or interested in working with us? Fill out the information below and we’ll be in touch.

Client Name*
First Last
Client Date of Birth:*
Client Address*
Street Address Address Line 2 City State ZIP Code
Contact Name (either client or other):
First Last
Contact Phone Number:*
Contact Email:*
Preferred Counselor
What type of service are you interested in?*
- Select All
- Behavior Consulting
- Counseling
- Music Therapy
- Recreational Therapy
When is the client available for appointments?*
- Day Time (3pm or earlier)
- Afternoon (3pm-5pm)
- Evenings (5pm-7pm)
- Weekends
If an opening is unavailable at this time for the service(s) you selected, do you wish to be placed on a waiting list?*
- Yes
- No
Do you currently have insurance or the Medicaid Waiver?*
- Yes, we have Medicaid Waiver (Add Case Manager Info Below)
- Yes, Insurance (add insurance info below)
- No, I am interested in self pay
Type of Insurance*
Preferred Contact Method:*
Case Manager Name*
Your Case Manager's Email*
Case Manager Phone*
Any other information you would like to share with us?

969 Keystone Way
Suite 100
Carmel, IN 46032