Appointment request

Client first name

Client last name

Client birthdate

Is client under 18 or requires the assistant of a parent or guardian?

Yes No

Parent/guardian first name

Parent/guardian last name

Appointment reason

Email

Phone number

Which clinician do you prefer to see? Meet our clinicians

Preferred appointment location

In-office (recommended) By tele-health (HIPAA-compliant video chat)

Preferred appointment availability

Monday Tuesday Wednesday Thursday No preference

Will you be using health insurance to pay for services?

Yes No

If Beech Tree is not in your insurance network, will you pay out of pocket?

Yes No

How did you hear about us?

Healthcare provider referral Personal referral Internet search Psychology Today Other

Who referred you to us?

How did you hear about us?

435 East Main Street, Suite 195
Greenwood, Indiana 46143