Appointment Request

We do not provide medication management services. We are out of network with all insurance companies.

Which clinician do you prefer to see? *

Client first name *

Client last name *

Client birthdate *

Parent or guardian first name (if client is under 18)

Parent or guardian last name (if client is under 18)

Phone number *

Email address *

Reason for appointment *0 / 500

Preferred appointment location *In office (recommended)By teleheath (HIPAA-compliant video chat)

Preferred availability (all appointments are Monday–Thursday)MondayTuesdayWednesdayThursday

Acknowledgement *I understand that providers do not accept insurance, and I have reviewed all service fees.

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Referral source0 / 100

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6411 South East Street
Suite A
Indianapolis, IN 46227

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