If you would like to request an appointment at Beech Tree, please complete and submit the form, below.Please enable JavaScript in your browser to complete this form.Name of person to be seen *FirstLastName (if parent/guardian)FirstLastDate of birth of person to be seen *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Phone *Reason for appointment *I would like to receive services *In the officeBy telehealthTelehealth refers to services delivered by HIPPA-compliant video chat. Please note services are telehealth only until at least January 15, 2021.Requested Service *TherapyAssessmentBothUnsurePlease note earliest possible availability for assessment is January 2021.Do you have a specific clinician you wish to see? *Choose ClinicianDr. Robbi CrainDr. Cara PrattDr. Colter SnethenDr. Brent LuebckeStephanie Bagato, LMFTAElise Birch, MA-AT, LMHCA, ATR-PKeeya Singer, MARyan Peleaux, MAJessica Vanderah, MANo preferenceWhen would you be available for appointments? Will you be using health insurance to pay for services? *YesNoPlease note our clinicians are In-Network with some, but not all plans, and can bill Out-of-Network for most other plans. Visit our Insurance and Fees page for more information.Name of Health Insurance Carrier *How did you learn about us?Physician/Professional ReferralPersonal ReferralGooglePsychology TodayOtherPhoneSubmitFax317 780 5755Mail6411 South East Street, Suite A Indianapolis, Indiana 46227Need directions?Phone317 780 5750
