New Patient Pre-Registration Form | Indiana Health Group

Thank you for considering IHG for your behavioral healthcare needs. We have developed this pre-registration form to streamline the intake process and connect with you quickly. Our team is committed to providing exceptional care and we appreciate your cooperation. If you have any questions, we will address them when we contact you to schedule your initial appointment.

We look forward to serving you soon!

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Scheduling Deposit

Scheduling Deposit Acknowledgement:(Required)

I understand a scheduling deposit will be required prior to scheduling.

Due to high demand and a shortage of appointment availability, we now require a deposit at the time of scheduling.

We have found that patients are more committed to their care and will be less likely to “no show” for their initial appointment.

This deposit will be credited to your initial appointment. Any remaining credit will be applied to future dates of service or refunded to you.

Therapy Evaluation = $100

Medication Management Evaluation = $200

Private Pay Provider = FULL FEE

Private pay provider rates can be found on the provider profile pages of our website - www.indianahealthgroup.com

Cancellation Policy

Cancellation Policy Acknowledgement:(Required)

I understand that I will forfeit my scheduling deposit if I miss my appointment or cancel with less than a 24-hour notice.

We require a 24-hour cancellation notice.

Due to limited appointment availability, this time gives patients on our waiting list the opportunity to be seen sooner.

Any missed appointment or appointments cancelled with less than 24-hour notice will be charged the full scheduling deposit amount. An additional deposit will be required to reschedule.

Patient Demographic Information

Patient's Legal Name:(Required)

First Last

Patient Prefers to Go By (Nickname):

Patient's Date of Birth:(Required)

Is the patient a minor?

Yes

Parent/Guardian Name:

First Last

Parent/Guardian Phone:

Parent/Guardian Email:

Patient Demographic Information

Patient's Address:(Required)

Street Address Address Line 2 City State ZIP Code

Patient's Primary Phone:(Required)

Patient's Secondary Phone:

Patient's Email:

Emergency Contact Information

Emergency Contact's Name:(Required)

First Last

Relationship to Patient:(Required)

Emergency Contact's Primary Phone:(Required)

Emergency Contact's Secondary Phone:

Emergency Contact's Email:

Patient Demographic Information

Legal Sex:(Required)

Female

Male

Gender Identity:

Male

Female

Trans-Male

Trans-Female

Non-Binary

Other

Sexual Orientation:

Heterosexual

Bisexual

Gay

Lesbian

N/A

Other

Referral Information

How did you hear about Indiana Health Group?(Required)

Friend / Family Member

Primary Care Provider

Behavioral Healthcare Provider

Inpatient Facility

Insurance Company

Psychology Today

Emberwood Center

Aware Recovery Care

Social Media Platform

Other

Referral Source Name:

Referral Source Address:

Street Address Address Line 2 City State ZIP Code

Referral Source Phone:

Referral Source Email:

Insurance Information

Please be aware that our office does not participate with Medicare, Medicaid, HIP, or Marketplace-based plans. Unfortunately, these plans prohibit our office or the covered member from filing a claim for out-of-network consideration. As a result, patients will be responsible for paying the full fee at the time of service./

Do you have insurance that you would like us to file on your behalf?(Required)

Yes

Insurance / Private Pay:(Required)

Anthem / Blue Cross Blue Shield - This does NOT include Medicare plans.

Cigna

ComPsych

Midwest Behavioral Health / New Avenues

Sagamore / IHN

United Healthcare / UBH / UMR - This does NOT include Medicare plans.

Other Insurance - If your insurance company is not listed above, our office is not in network. We may be able to file your claims for out of network consideration.

Our practice is OUT OF NETWORK with the insurance you selected. Your scheduling deposit will be applied to your initial visit. Any balance over the deposit amount will be due in full at the time of service. We will gladly file your claims for possible out-of-network reimbursement as a courtesy.

Primary Insured Name:

Identification Number:

Group Number:

Insurance Phone Number:

Claims Address

Street Address Address Line 2 City State ZIP Code

Upload FRONT & BACK of Insurance Card:

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Contract Billing

My services will be covered by:

AWARE Recovery Services

Emberwood Center

Treatment Information

Please describe the reason you are seeking treatment:(Required)

I prefer to be seen via:(Required)

Telehealth

In Office

Either

Provider Selection

I am seeking a provider for:(Required)

Medication Management

Therapy

Both - Medication Management & Therapy

Please choose the MEDICATION MANGEMENT PROVIDER that you would like to schedule with:

FIRST AVAILABLE

Chris Bojrab, MD

Deborah Bykowski, PMHNP-BC (Not Currently Accepting New Patients)

Deborah Carpenter, PMHCNS-BC (New Patients by Direct Referral Only)

Beili Dong, MD (Not Currently Accepting New Patients)

Tyler Flaningham, MD

Kirsten Hammersley, CPNP-BC, PMHNP-BC

Shiela Irick, MD (New Patients by Direct Referral Only)

Nancy Jungemann, PMHNP-BC

Danita Lively, MD (Not Currently Accepting New Patients)

Barbara Logan DNP, FNP-BC, PMHNP-BC (New Patients by Direct Referral Only)

Christine Miller, DO (+ Therapy)

Sanjay Mishra, MD (New Patients by Direct Referral Only)

Jill Oliver, PMHCNS-BC

Terry Parrish, MD (Telehealth Only) (Not Currently Accepting New Patients)

Jane Rapinchuck MD (Not Currently Accepting New Patients)

Daniel Shepler, PMHNP-BC

Michael Webber, MD (New Patients by Direct Referral Only)

Steve Wilson, PMHCNS-BC

Please choose the THERAPIST that you would like to schedule with:

FIRST AVAILABLE

Nirav Bigelow PhD, PsyD

Andrew Brothers, PhD

Katherine (Katie) Clendenen, LMHC

Jenna Doyle, LMHC

Christina Falink, LCSW

Corey Falink, LMHC (New Patients by Direct Referral Only)

Jessica Fogle, LCSW (New Patients by Direct Referral Only)

Elizabeth Goebel, LMHC (Not Accepting New Patients)

Marcy Haboush, LCSW (New Patients by Direct Referral Only)

Marabeth Holland, LMHC

Beverly Inman-Dunigan, LCSW (Telehealth Only)

Elizabeth Irick, LMHC

Jennifer Jansen, LCSW (Not Accepting New Patients)

Robert Jeffries, PhD

Rich Jones, PhD

Kimberly Keller, LMHC (+ EMDR)

Seth Kleiman, LMHC

Kourtney Klepfer, LCSW (+ EMDR) (Not Accepting New Patients)

Maryann Lake, LCSW

Bethany Littrell, LMHC (Not Accepting New Patients)

Christine Miller, DO (+ Medication Mangement)

Scott Minnich, MSW, LSW

Laurie Moyer, LCSW, ATR (+ Art Therapy)

Jennifer Myers, LCSW

Shaunna Norris, LCSW

Tina Ramseur, LMHC, LCAC

Michelle Rinzel, LCSW

Mary Roth, LCSW (Not Accepting New Patients)

Carrie Schaefer, LCSW (New Patients by Direct Referral Only)

Camille Sexton-Villalta, PhD

Francia Siler, LCSW (Fluent in Spanish)

Jenn Stepic-Wenzel, LMHC (Not Accepting New Patients)

Polly Westcott, PsyD

Contact

Is there anything else you would like to share with us prior to scheduling?