Request an Appointment Form

Name *

First Name Last Name

Date of Birth *

Guardian Name if Patient Under 18

Phone Number *

Area Code Phone Number

E-mail *

Referring Physician or Therapist *

First Time Visit? *

Yes No

Insurance Carrier *

May we leave a detailed voicemail? *

Yes No

Preferred day of week for appointment *

Monday Tuesday Wednesday Thursday

Preferred time of day *

7 am-9 am 9am-1130am 1pm-3pm

***We must receive your New Patient Paperwork and any Release of Information forms within 24 BUSINESS HOURS of your initial appointment***

Please note that:

Appointment time requested may not be available.

Care of Minors:
- If patient is under the age of 18 and parent(s) are seperated, divorced, or not legally married we require the court documentation indicating identifying custodial parent prior to being able to schedule an appointment with Indy Behavioral Health.
- If you are a court appointed guardian of a minor we require the court documentation identifying court appointed guadianship prior to being able to schedule an appointment with Indy Behavioral Health.
If you are an adult requesting medication management for ADHD, we require a previous psychological evaluation that our provider will review prior to scheduling initial appointment.

**We will attempt to contact you for scheduling a maximum of three times. If you have not returned our call, we will assume that you have obtained services elsewhere. Thank you.